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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.TON AVE., STOCKTON, CA Telephone (209) 466-6781 T,e 1PEnMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) application is ' or sewage or No. 1862 for welilpump and the Rules and Regulations of the San ioaquin b made to the San Joaquin Local Health District far a permit to construct and/or install the work herein described.This I Application is hereby Ordinance No. made in compliance with San Joaquin County l` Local Health District. G PM City f/2 QL� _ Lot Size Job Address i / 4D. Phone 0: bi Address �d /0O /4� i Owner's Name I S _ License No. cS� Phone Contractor's Name DESTR❑ UCTION L3NEW WELL LDWELL REPLACEMENT OTHER ❑ TYPE OF WELLIPUMP: SYSTEM REPAIR ❑ pflOp. LINE PUMP INSTALLATION ❑ DISPOSAL FLD. SEWER LINES OTHER WELL PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK � AGRICULTURE WELL FOUNDATIONIONS ... CONSTRUCTION SPECIFICATDia. of Well Casing i INTENDED USE TYPE OF WELL PROBLEM Dia. of Well Excavation 0 ❑ Open Bottom ❑ Manteca Specifications I Q Industrial ❑ Tracy Type of Casing Type of Grout 7-1 Domestic/Private ❑ Gravel Pack ❑ Delta , Depth of Grout Seal El Public ❑ Other .I Surface Seal installed by r ( Jgpprox. Depth C3 Eastern State Work Done . H.P. Repair Work Done ❑ Type of Pump �— Sealing Material (top 50'1 5 ..- - - -- ❑ Well Diameter _r-- 7 WeA Destruction Filler Material (Below 50'1 Depth DESTRUCTION ❑ (No septic system permitted if public sewer is ` TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION Q available within 200 feet.) § Commercial 4 Other 4 � Installation will serve: Residence Number of living units: � � � Number of bedrooms�— Water table depth Character of soil to a depth of 3 feet: ` k Capacity) No. Compartments Method of Disposal SEPTIC TANKType/Mfg _ r PKG. TREATMENT PLT.❑ Line i ..,� - ---�� Property + Distance to nearest: _Well Foundation i Total iengthlsize LEACHING LINE No. & Length of lines Ion Property Line�— . ti � FILTEfl BED,; ❑ Distance to nearest: Well—�— Number ❑ Depth Size party Line�- SEEPAGE PITS Foundation Pro SUMPS L._J ElDistance to nearest: Well DISPOSAL PONDS ❑ cern that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an I hereby certify rules and regulatot ions of the San Joaquin Local Health District. signature to workman's compensation laws of California." Contractor'sns subject t workman's compensa Horne owner or licensed agent's signature certifies the following, I certify that in the performance of the work for which this permit is issued, shall n employ any person in such manner as to become subject let certifies the foil "I certify that in th performance of the work for which this permit is issued,1 shalt employ tion laws o alifornia.' (� ns Complete drawing on reverse side. r�f It for all r iions. The apPl' a mu � GC/El�6�_ Date: Title: Signed _ r FOR DEPARTMENT USE ONLY -2�2 9 � (' Date Area Application Accepted by Date Date� Final Inspection by Pit or Grout Inspection by € Additional Comments: ❑ Manteca 823-7104 ❑Tracy 835-6385 ❑ Stk 466 6781 ❑ Lodi t 369-3621 Stk., CA X201 Applicant- Return all copies to:}{Environmental Health Permit/Sen+ices 1601 E. Hazelton Ave., P.O. Box ' 1 HATE PERMIT'NO. FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY �.„ a .INFO, +EH 13-24(REV.10183)- { - EH 14-28