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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL'HEALTH DISTRICT f 1601 E. HAZEL T ON AVE., STOCKTON, CA Lam- � t k Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) — Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is r go or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewa r Local Health District. � X75 �.�h _ 3 City 8 Lot Size 65 X 33 PM Job Address • ' 5 { �Q V Address 37�� •� �fPJ Phone �� Owner's Name Y C actor Address License'No, Phone WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 � TYPE OF WELL/PUMP: NEW L ❑ -_ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK WER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRI TURE WELL OTHER WELL— PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA TRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of cavation Dia. of Well Casing ' e of Casing Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy TYP g Type of Grout I'1 Public Cl Other Cl Delta Depth of Grout Seal 1 Irrigation Approx. Depth l I Eastern Surface Seal Installed by - r H P State Work Done Repair Work Done ❑ Type of Pump Well Destruction ❑ Well Diameter Sealing Material (top 501 c Depth 1 Filler Material (Below 50') " TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION LI DESTRUCTION INo septic system permitted it public sewer is vailable within 200 feet.) Installation will serve: Residence '� Commercial— Other Number of living units: Number of bedrooms i Water table depth I Character of soil to a depth of 3 feet: rSEPTIC TANK El Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. $.Length of lines Total Iengthlsize 1 FILTER BED 11Distance to nearest: Well Foundation Property Line 1 -� SEEPAGE PITS I I Depth Size Number i #.--. , SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i this application and that the work will be done in accordance with San Joaquin county ordinances, state laws,'and I hereby certify that I have prepared ' rules and regulations of the San Joaquin Local Health Diltrict. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work far which this permit is issued, I shall not cting signature employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contra certifies the following: "I-certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa ` ' tion laws of California." d he applica t call for all r red inspections. Complete drawing on reverse side. Signed X ,�._ Title: Date: i A FOR DEPARTMENT USE ONLY (/w Application Accepted by Data v Area 13 i Date Pit or Grout Inspection by Dae F' spection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369 3621 ❑ Manteca 823-7104 Tracy 835.6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., GA 9x201 FEE. AMOUNT RUE AMOUNT REMITTED' i 'aGASH RECEIVED fjY DATE # PERMIT NO. 'INFO S -� •sa *,EH 13-241REv. /n51 '- EH 14-26