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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplete in Triplicate) 005-- _-wo— ,07 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 made in compliance with-San JoaquinC un_ty Ordinance No.549 for a or 2 for well/pump and the Rules and Regulations of the San Joaquin Local Health District 7 . t> J b�d7frl s �^.__.___—._ _ _ � t City D Lot Size r PM S,3 Owner's Name Address Phone U y' Phone 'y`vq Contractor 1� / Address ense Na TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ �l PUMP INSTALLATIO SYSTEM REPAIR ❑ OTHER ❑ DISTANCE.TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA Y ❑ Industrial ❑ Open Bottom C] Manteca Dia. of Well Excavatio Dia. of Well Casing g Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �[ �- M Public n Other F1 Delta Depth of Grout Seal _I pe of Grout I I Irrigation —.-Approx. Depth i I Eastern Suri ce Seal Installed by Repair Work Done ❑ Type of Pump _ H.P, State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 f Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I Wo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 1 SEPTIC TANK I❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line c LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number i SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ l 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: "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." Contractor's hiring or sub-contracting signature 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." The ap c II fo al gpfr$d 'ns ct' n Complete drawing on reverse side.� �7 Sign X j/Y/ Title:�� a224 Z_ Data: 'C FOR DEPARTMENT USE ONLY Application Accepted by Date _.- Area ° Pit or Grout Inspection by Date Final inspection by Date 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. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE EPERMIT'NO. INFO �"'� /�C SHQEH Ia-21(REV.1 M 51 1 Y �� Q v f 1"T`� 2 1,2-o XEH t/-26LJ II `�V ...LLv// C!C,�ll