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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i . 1601 E. HAZEL T ON AVE., STOCKTON, CA ,ff Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED +: (Complete in Triplicate) he work . This cation is all t madApplication inp+ante with San joaquinade tothe nCounty Ordinance Na.uin Local th District for a 549 for sewage or permit No. 1862 forcweil/dpump atnd the Rules and hereinR Regulations of he San l Joaquin Local Health District. { . 4City of Size PM .lob Address � - J �"Pho �1 Owner's Name Address n F l License Nv. Phone J �� Contractor - V` Address TYPE OF WELL/PUMP: NEW WELL ❑ ELL REPLACEMENT ❑ DESTRUCTION C] t PUMP INSTALLATION SYSTEM REPAIR Cl OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP..LINE !y i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f I ❑ Industria, ❑,_Open Bottom ❑ Manteca Dias. off Weil Excavation Dia. of Well Casing I`-"" - '" Specifications �- ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing ❑ Other ,1 CI Delta Depth of Grout Seal Type of Grout - f 1 Public 1'' i I Irrigation �..Approx. Dept stern Sy�iace e f Instalied by Repair Work Done ❑ Type of Pump H.P. (�• State Work Done ' Sealing Material Itop 50'1 1 Well Destruction ❑ Well Diameter - Filler Material IBolow 50'1 � Depth � ` TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION l 1 i DESTRUCTION t.I ft)septic system permitted if public sewer.is - available within 200 feet.) Installationwill serve: Residence Commercial — Other i Number of living units: Number of bedrooms _ g r a Water table depth Character of soil to a r depth of 3 feet: 1 SEPTIC TANK -Type/Mfg P' "' Capacity No. Compartments PKG. TREATMENT PLT:-b' Method of Disposal , f • Distance to nearest: .. �Well - .- Foundation Property Linetry A4i Total length/size— LEACHING . LINE� ❑ No &a Length of lines ' Y Foundation I T--"` Property Line t 1" FILTER BED i ❑ Distance to nearest: Well SEEPAGE PITS !r �'1 11, Elepth., - Size Number t .. SUMPS ❑ Distance to nearest: Welt ' Foundation Property Line DISPOSAL PO DS El r { I hereby cert) t at I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and re lati ns of the San Joaquin Local Health District. Home owns or Ii ensed a t signature certifies the following: ".I certify that in the performance of the work for which this permil'ki�issued, I shall not employ any ers in suc man er as to becom biect to rkman's compensation laws of California." Contractor's hiring or sutrcontracting signature ` certifies the Ilo ing: "I c rtify t at i the o ce of th ork for which this permit is issued, I shall employ persons subject iowo�kman's compensa- tion laws of I rnia." i The appli t al r re a 'n pec n mpl drawing on rev s ' i �] Title: Date: Signed X L R DEPARTMENT USE ONLY / Area t 6;2 Application Accepted by Date j9 Pit or Grout Inspection by - ate Final Inspection by Date Additional Comments: ' f t Ll Stk 466-6781 E) Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 s i FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. G INFO 1 +.EH 13-24 MEt1. '?5- EH 14-26 _.