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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM MATE ISSUED r fir},:�:s• , (Complete in Triplicate) tiF i _ fix. r , application is Application is hereby made to the San Joaquin Local Health District for permit to construct and/or install the work herein described. This or No. 1862 for well/pump and the Ryles and Regulations of the San made in compliance with San Joaquin County Ordinance No.549 for sewage Joaquin Local Health District. f /1[GGF �T J- ri/1Cn t/Off 7 � City Lot Size PM ' Job Address �—� k Owner's Name c ar:� L C Address. Phone = Phone ''.: Contractor e r Address e i License No. �— TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 1-1DISTANCE TO NEAREST: SEPTIC TANK S R LINES DISPOSAL FLD. PROP. LINE FOUNDATION GRICULTURE WELL OTHER WELL PITS/SUMPS ` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial [D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing T e of Casing Specifications ❑ Domestic/Private ❑ Gravel Pack c yp g Type of Grout ❑ Public ❑ Other VD;a Depth of Grout Seal❑ Irrigation _ Approx. Deptt 5-n Surface Seal Installed by Repair Work Dane ❑ Type of Pump H.P. State Work Dane Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material IBelow 501 {� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION X alvailabpticle system in permitted if public sewer is Installation will serve: Residence— Commercial_ Other * Number of living units: Number of bedrooms 4 Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ! Method of Disposal Distance to nearest: Well Foundation Property Line m�m ._ lV h LEACHING LINE C1No. & Length of lines Total length/size' FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS ❑ Depth Size Number,., SUMPS ❑ Distance to nearest: 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 rules arid 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 employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 applicant st call for II r uire i spections. Complete drawing on reverse side. Signed t/� Title: Date: FOR DEPARTMENT USE-ONLY 1. ¢ �- I `Date f� -2p Area i Application Accepted by - , Date Final Inspection by Pit or Grout Inspection by Daze r Additional Comments: NAp tk 466-6781 C1 Lodi 369-3621 0 Manteca 823-7104 11 Tracy 8355-6385 licant Return all copies to! Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEEAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE` PERMIT N0. INFO + EH 13-24(REV.I/s 5) 1 Q� 1.pq f�r�yt$S �S--13c�.,3. ....- EH 14-26 _.,..._-.. .. '