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APPLICATION FOR PERMIT SAN JOAQUIN LOCALHEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 1 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED" wo ., ..v r. (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.TMs application is e or No. 1862 for well/pump and the Ryles and Regulations of the San Joaqu made in compliance with San Joaquin County Ordinance No.549 for sewagin Local Health District. City Lot Size PM Job Address 9�I� ��-'t.Lr �i _rds ref -PhoneOwner's Name�� ` �fA,,'X46�� rPhone AddressIIC�t,"� License No. TYPE OF WELL/PUMP: NEW WELL C] \, WELL REPLACEMENT 13 DESTRUCTION E:PUMP INSTALLATION ❑ , `"` SYSTEM REPAIR Pr OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS s INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I�Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ! ❑ Delta Depth of Grout Seal' Type'of Grout ❑ Irrigation ---Approx. Depth Eastern rrt� Surface Seal Installed by Repair Work Done ❑ Type of Pumps H.P. -Z Stat Work Done ` Well Destruction ElWell Diameter Sealing Material {tap 50') Depth Filler Material iBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is II available within 200 feet.) . Installation will serve: Residence Commercial; Other Number of living units: ;Number of bedrooms Character of soil to a depth of feet: Water table depth 3 ` r' Capacity E No. Compartments ' SEPTIC TANK ❑ Type/Mfg (� i� PKG. TREATMENT PLT. 71 !/ ' Method of Disposal �- r ' Distance to nearest:' *Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines r "" "" T"Total length/size T. FILTER BED 171 Distance to nearest: Well Foundation Property Line ' 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 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 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "f 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 al red inspections. Complete drawing on re se side ' � N3 Signed 7C_�,� 1 Title: Date: i FOR DEPARTMENT USE ONLY _ � Area i Application Accepted by ' Date r Pit or Grout Inspection by Date Final lnspection by Date f� I Additional Comments: E3Stk 466-6781 L1 Lodi 369-3621 C(Manteca 823-7104 El Tracy 835 6385 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, _Stk., CA 95201' s.. FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO: INFO +EH 13-24(RE:V.1/s5) �/ �• �r` ��'' EH 1426 - - '