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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES '"YEAR FROM DATE ISSUED (Complete in Triplicate) � Application is f winstall.the work th made de to oJhe San Gou Q :ty Ord nalnce No.549 for sewage or permitHealth District for a and/or No. 1862 for welllpumlherein p and the R l s and Regulations t of the SanJoaquin made in comp Local Health District. . , 7 City �` Lot Size �7 PM f Job Address l Owner's Name Address �,%. f t t�FIJ Phone Contractor Address 9��J—� License too. Phone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ _ PUMP INSTALLATION Ll -R REPAIR 171 OTHER ❑ SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WI=LL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications Type of Casing r El Domestic/Private Ll Gravel Pack ❑ Tracy i ❑ Other ❑ Type of Grout - delta Depth of Grout Seal l•l Public I F I I I Irrigation __Approxi Depth I I Eastern Surface Seal Installed by 1 H P State Work Done Repair Work Done ❑ Type of Pump I Sealing Material Itop 50'1 Well Destruction ❑ Well Diameter Depth I Filler Material (Below TYPE OF SEPTIC WORK: NEW INSTALLATION I I ryREPAIR1ADDlTION l fI DESTRUCTIO IN labPerwi wit 200 feet.)stervilpqrmttif public sewer is Installation Will serve: Residence Commercial_ Others Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet:f No. Compartments SEPTIC TANK ❑ Type/Mfg+ t Capacity f w s Method of Disposal PKC, TREATMENT PLT. ❑ Property Line Distance to nearest: Wel{ Foundation P V LEACHING LINE ❑ No. & Length of lines FILTER BED - -.Total length/size ❑ Distance to nearest: Well Foundation. Property Line � I Depth I. Size Number SEEPAGE PITS Property Line SUMPS L-1Distance oto nearest: Well Foundation p Y { DISPOSAL PONDS ❑ I hereby certify that 1 have prepared ill be done in accordance with San Joaquin county ordinances, state laws, and ks: application and that the work w 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 # of employ any person in such manner as to become subject to workman's compensation laws 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 appli ust ca I for all required inspections. Complete drawing on reverse side. Date: Signed Title: FOR DEPARTMENT USE ONLY i Date Area Application Accepted by Pit or Grout Inspection by Date f=inal Inspection b Dai i (p r Additional Comments: ❑ Stk 466-6781 12 Lodi 369-3621 ❑ Manteca 823- 104 ❑ Tracy 835-6385 Applicant- Return all copies to: Envir�nmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK RECEIVED BY DATE PERMIT NO. I INFO AMOUN��TD77UUE�E AMOUNT (� a.EH 13-24(REV.1/H5) EH 14-2a 1