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APPLICATION FOR PERMIT p AY Wi SAN JOAQUIN LOCAL HEALTH DISTRICT ECdEYVED 1601 E. HAZE.T ON AVE_ STOCKTON, CA NOV 12 1987 Telephone (209) 466-6781 1PERMIT EXPIRES TYEAR FROM DATE ISSUED MENSAL HEALTH ►yVIRON (Complete in Triplicate) SERVICES M41h llcation is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein des red. is app' or No. 1852 far well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage \� Local Health District. Lot Size PM Jab Address A Addre �9k Phone Owner's Nam JJ jiq Contractor Address License No.y!� Phone /� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION ❑ PUMP INSTALLATIOSN PROP. LINE SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. FOUNDATION AGRICULTURE WELL OTHER WELL PlTS15UMP5 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing- ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excav tion �( Type of Casing Specifications Domestic/ ❑ Private Gravel Packt J� Type of Grout Public f_-1 Other F1 Deltata Depth of Grout Seal I i Irrigation x ._Approx...Depth 1.1 Eastern Surface Seal Installed by 'i Repair Work Done ❑ Type of Pump H.P. State Work Done , Well Destruction El Weil Diameter Sealing Material (top 501 Depth Filler Material (Below 50') ` TYPE OF SEPTIC WORK: NEW INSTALLATION to REPAIR/ADDITION I.! DESTRUCTION I i aNailabpelwithin 200 feetstem .) if public sewer is ^ 1 Installation will serve: Residence_.1. Commercial Other G Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK ElType/Mfg Capacity :1 Method of Disposal PKG. TREATMENT PLT. ❑ i Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length vt lines Total length/size FILTER BED 11 Distance to nearest: Well Foundation Property Line t: SEEPAGE PITS ['I Depth Size _ Number - ❑ Distance to nearest: Well Foundation Property Line SUMPS , k DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and ' rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "l certify that in the performance of the work for which this permit is issued, I shall not to become subject to workman's compensation laws of California." Contractor's orworkmana u Isg signature employ any person in such manner a5 certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ pesubject r nsa- tion laws of California." The applicant must call Jor all required inspections. Complete drawing on reverse side. Signed X Title: Date: / FORD ARTMENT USE ONLY Date ,r �J Area Application Accepted by Pit or Grout Inspection by Date Final Inspection by Date t Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT Nb. INFO i EH 13-241REV.�iIK51 EH 1426