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APPLICATION FOR PERMIT �• d r� SAN JOAQUIN LOCAL?HEALTH DISTRICT r 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209).466-6781 !PERMIT EXPIRES 1'YEAR FROM DATE ISSUED'' (Complete in Triplicate) /or'install the work n described.This cation is Application is hereby made to the San Joaquin County Ordinance nalHealth nce No.649 for istrict sefor a wage or permit No. 1862 for ell/dpump and the Ryles and'Regulations of he San l Joaquin made in compliance with San Joaquin x . Local Health District. #,- City `Lot Size PM , Job Address y _ Phone 77� Owner's Name Address — License Phone Contractor , j(o rskc Address//_�••'% "'"` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER .0' DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES "'FOUNDATION` AGRICULTURE WELL OTHER WELL `PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS, pia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Type of Casing Specifications ;?Domestic/Private ❑ Gravel Pack ❑ Tracy yp g Type of Grout Ll Public . ❑ Other r ❑ Delta Depth of Grout Seal , ❑ Irrigation ---Approx. Depth H.P Surface Seal Installed by i Repair Work Done I Type of Pump State Work Done (top 50'I Well Destruction LlSealin Well Diameter 9 Material Depth ' Filler Material (Below 50') ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is i� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/AUDITIONavailable within 200 feet.) Installation will serve: Residence�Commercial Other + } Number of living units: Number of bedrooms"r Water table depth Character of soil to a depth of 3 feet:' . Nd-Compartments SEPTIC TANK ❑ Type/Mfg Capacity K Method of Disposal PKG. TREATMENT PLT. ❑ t Pr=Line- SEEPAGE -1�..5_tiS3S _ ! !. Distance to nearest: Well Foundation C Total leng LEACHING LINE ❑ No. & Length of lines P FILTER BED ❑ Distance to nearest: Well Foundation ` PITS ❑ Depth I Size Number Distance to nearest:. ,_Well _Foundation 1� SUMPS , ,.� .�- ,._❑_.. ,...�,,,.,�.-, . - �.- DISPOSAL PONDS ❑ F ll be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application and that the work wi r rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following:111 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." The applicant must call f ll required inspections. Complete drawing on rev side. r Signed X� � f Date: Title: 6 r 0 DEPARTMENT USE.ONLY Area—9 Application Accepted by / Date r �7 I 1 V Date�� Final Inspection by Date '/�7`�' Pit or Grout Inspecti Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6386 i Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 E I , FEE K RECEIVED BY DATE PERMWNO. INFO AMOUNT DUE AMOUNT REMITTED H +AH 13-24(REV.5/s r) EH 1426 - l