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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) cribe t and/or'install the work n des madecation is in corms lance with Sano the Joaqu nncoungty Ordinance Nocal th District for 8 o. 549 for sewage or permit No 1862 forcwell/pump and the Rules and IR Regulations of)the Sanis Joaquin made in compliance r Locale Health District, 2 Y� city Lot Size PM Job Address Phone Owner's Name Address Contractor a Address e License No. Phone ' TYPE OF WELL/PUMP: NEW WELL 171 'WELL REPLACEMENT ❑ . ` ; TDESTRUCTION Cl I y PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PRPP: LINE��^ .. FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS PROBLEM AREA INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i Dia- of Well Casing ^ ❑ Oen Bottom - ❑ Manteca Dia. of Well Excavation `�. ❑ Industrial � p Specifications l� } ❑ Domestic/Private ❑ Gravel�Pack ❑ Tracy Type(._Casing µ } rt Type of Grout �v 11 's '� � ��'❑ Delta' � "'"Depth af'Grout Seal' _ I FI Public '�. t ❑ Other. , _ I I Irrigation Approx. Depth I I Eastern Surface Seallns ailed byr 3 Type of PHPState Work Done Repair Work Done ❑ Pump H.P, r A Well Destruction ❑ Well Diameter SealinMat'erial Ma�* wp 50'1 I 4 Depth Filler 50'1 R TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITDESTRUCTION'I• availabNo �erwthin 200{ec system ret1l�ed if p�blic sewer is i, t : kInstallation wili`serve: Residence— Commercial— Other .. f. i 7 \ Number of living units: Number of bedrooms 1 Water table depth I Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Method of Disposal PKG. TREATMENT PLT. ❑ , y Line Distance to nearest: Well Foundation? Propert r LEACHING LINE ClTotal length/size.." No. & Length of fines FILTER BED ❑ " Distance to nearest: Well Foundation Property Line SEEPAGE PITS I Depth Sire ` Number SUMPS Ll Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ * r++ I I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,.stale laws, and rules and regulations of the San Joaquin Local Health Dill rict. 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 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 applicant must call for all required inspections. Complete drawing on reverse side. Title:. Q C ' Date: Signed X I FOR DEPARTMENT USE ONLY Date ''� Area Application Accepted by �p Pit or Grout Inspection by Date Final Inspection by Date `r U Additional Comments: . ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 ❑ Tracy 835 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK RECEIVED BY DATE PERMIT"NO. INFO AMOUNT DUE ,7A�M4/U�N7 REMITTED �jCASH a,EH 13-24(REV. 4�a EH 14-28 r.