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rM�W APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r install the work n describe . < Application is heieby wimade th Santhe JoaquinnnCounguin Local Health District for a ty Ordinance No. 549 for sewage or permit No. 1862 forcwell/dpuomp and the Rules and'R gulations of tthe Sanis application Joaquin made in comp �' �'•� Local Health District. !/ I PM City �-+' � n Lot Size Job Address r� Phone Owner's !Name 01 1 G' �ddress Address b License No Phone Contractor ,,,.TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ k--DESTRUCTION-❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER [I SEWER LINES DISPOSAL FLD. PROP, LINE DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS r ; ' FOUNDATION AGRICULTURE WELL OTHER WELL t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy- Type of Casing Type of Grout M Public ❑ Other C Delta , Depth of Grout Seal I I Irrigation __-Approx. Depth l I Eastern 1"' Surface Seal installed by A H p State Work Done r Repair Work Done ❑ Type of Pump Well Destruction LJWell Diameter Sealing Material Stop 50'I Depth Filler Material (Below 501 C f TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I ! DESTRUCTION I 1 INo septic system permitted it public sewer is available within 200 feet.) I r Installation will serve: Residence�, Commercial Other Number of living units: Number of bedrooms r a/ �Q r(i4� Water table depth Character of soil to a depth of 3 feet: -�a.r�� SEPTIC TANK Type/Mfg _ r h^�f�� Capacity ._ — No. Compartments PKG. TREATMENT PLT. ❑ h Method of Disposaal € Distance to nearest: Well �o� Foundation _..._.Property Line LEACHING LINE No. & Length of lines Total length/size r _ Line FILTER I FILTER BED ❑: .Distance to nearest: Welkl_�f Fourldatiori__ �— Property I - - Size -�!Numbe"r' SEEPAGE PITS Depth I •�- SUMPS El Distance to nearest: Well I to 1 Foundation 1511')— Property Line .— 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 Di§trict. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work fbr which this permit is issued, I shall not f 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 comp nsa- tion laws of California." The applicant must call for all req ired • spections. Complete drawing.on reverse side. Q Title: I a Date: Signed X_ 141 R DEP TMENT USE ONLY Date rea Application Accepted by � ' �'d or Grout Inspection by O Rate Final Inspection b Date F a �® CAdditional Comments: LJ Stk 466-6781 El Lodi 369-3621 C1 Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. INFO ♦.EH 13-24(REV.1/H 5) l' EH 14-26 3