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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Ito construct Application is!hre with a to theJoaS nnJoaquin Local County Ordinance lth D549 for sewage or No. 1562 forwell/pump and the Rul s and R gulations application of he SanJoaquin made in copa Local Health District. _J CityLot Size .PM ; . . Job Address � I�_1 �. SC Address Owner's Name _ J Phone Contractor's Name License No. Phone -a 4� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK + PITS%SUMPS x FOUIVDATION� AGR'lCUETURE-WELL' OTFiEk WELL.� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ---- Dia. of Well Casing ❑ Industrial ❑ Open Bottom Ca❑ Manteca Dia. of Excavation Specifications F-1 Tracy Type of Casing Domestic/Private ❑ Gravel Pack ❑ Delta Depth of Grout Seal Type of Grout ❑ Other F [I Public ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal installed by Type of PUMP. H.P. State Work Done Ell 'Repair Work Done TYP ' Well Destruction F1 Well Diameter Sealing Material [top 50'1 Depth Filler Material (Below 501 Y TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INO availsepti systemithin permitted if public sewer is le Installation Will serve: — Other serve: Residence—� L_. Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Capacity No. Compartments f SEPTIC TANK ❑ Type/Mfg Method of Disposal If PKG. TREATMENT PLT. ❑ f. Foundation Property Line Distance to nearest: Well -tet .I Total length/size LEACHING LINE ❑ No. & Length of lines Property Line FILTER BED ❑ Distance to nearest: Well Foundation l Size Number — SEEPAGE PITS ❑ Depth _ -:SUMPS ❑ Distance.,to Hearst:. Well �� Foundation 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 P 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 far which this permit is issued, L signature shat not r employ any person in such manner as tol become subject to workman's compensation laws of California." ployactosons'subject t workman's ring or compensa- 4 certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ pe tion laws of California." i The applicant m I for require ins pe 'ons. mplete drawing on rev a idc Title: Date: k Signed �. FOR DEP RTMENT USE ONLY 1;,7 � / Date !� ea Application Accepted by l2-Z*3 r I 1 Final Inspection by Date Pit or Grout Inspection by Date i Additional Comments: ❑ Stk 466-6751 ❑ Lodi 369-3621 ❑ Manteca 823 7104 [1 Tracy 83r),-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK RECEIVED By DATE PERMIT`'N0. FEE AMOUNT DUE AMOUNT REMITTED CASH I INFO b1,gsas--ISO a EH 13.24(REV.10183) EH W26