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r APPLICATION FOR PERMIT S� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781- [PERMIT EXPIRES ''YEAR FROM DATE ISSUED (Complete in Triplicated lor install the work .This cation is Application is hereby made to the San Joaquin Local Health District for a permit o. 1862 forto cwellldpump and the Rules and herein Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage t �-.� Local Health District. ll �4 CitOt�ill Lot Size PM Job Address r -�t�, Phone Owner's Name. �,.. � J Address -� - ;,�, •�--�""� License No.�-.~---Phone Contractor Address NEW WELL ❑ WELL REPLACEMENT 71 DESTRUCTION - TYPE OF WELL/PUMP: SYSTEM REPAIR 171 OTHER ❑ PUMP INSTALLATION ❑ SEWER LINES DISPOSAL FLD. PROP, LINE DISTANCE TO NEAREST: SEPTIC TANK PITSISUMPS I _ FOUNDATION _�.-- AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications T e - r - ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy -Type of Casing Type of Grout Other Ll Delta Depth of Grout 11 Seal t "f"1 Public _ � - —.Approx. Surface Seai Installed by . Depth I I Eastern g I I Irrigation r �- State Work Done l- Repair Work Done •❑ Type of Pump H.P. " —�� Sealing Material (top 50'1 C Well Destruction ❑ Well Diameter .— I� Depth-T` Filler Material (Below 50'1 TYPE OF SEPTIC WORK; NEW INSTALLATION l 1 REPAIR/ADDITION l 1 DESTRUCT( NII atvailableoi lwit isy�An 200 feet.) if public sewer is Installation will serve: Residence'L4 Commercial— 'Other ' f Number of living units: "` Number of bedrooms Water table depth Character of soil to a depI6 of 3 feet: Capacity No- Compartments SEPTIC TANK '(3Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ }.f I ~� ndation Property Line Distance to nearest: Well Fou T 1Total length/size LEACHING LINE ❑ No. & Length of lines property Line FILTER BED ❑ Distance to nearest: Well Foundation r SEEPAGE PITS l I 'Depth Size Number i T Cl Distance to nearest: Well Foundation Property Line SUMPS DISPOSAL PONDS I 1 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 far 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 L certifFii - rtify that in the rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa-- tion - r The all required s c ns. Complete drawing on reveerse sides. Title: ter -/ �iDate: Sign ` L FOR DEPARTMENT USE ONLY r Date Area • Application Accepted by"R Pit or Grout Inspection by ate_�� Final Inspection by Date Additional Comments: ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmantal Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 { RECEIVED BY DATE PERMIT NO. E ffFEE EjSNT DUE AMOUNT REMITTED GASH + EH 13.24(REV.r i a 5Y `' �/. 7EH 14-2B , r _