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rs APPLICATION_FOR PERMIT SAN JOAQUIN_LOCAL HEALTH DISTRICT 1601 E. HAZEL ION AVE.,.STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' (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.This application is or No. 1862 for welt/pump and the flutes and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage Local Health District. �F /Xi(Jp PM City Lot Size i Job Address - � ' i Owner's Name Address Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR CIOTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL— INTENDED ELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEC +,, Dia. f xcavation Dia. of Well Casing El Industrial ❑ Open Bottom L1 Manteca Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Trac ., s Type of Casing € ❑ Public ❑ Other ' Delta } Depth of Grout Seal '° 1 -_Type of Grout " ❑ Irrigation ox. Depth ❑ Eastern J Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done Well Des ion ❑ Well Diameter Sealing Material hop 501 ' -F Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION D 'DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet.) t j installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms V Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ` Type/Mfg Capacity No. Compartments ` E3Method of Disposal PKG. TREATMENT PLT. Distance"to nearest: Well foundation Property Line — LEACHING LINE ❑ No. & Length of lines Total length/size l FILTER BED . ❑ Distance to nearest: well Foundation Property Line SEEPAGE PITS ❑ Depth Y 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:"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." T n mus c for all required inspe ions. Complete drawing on reverse side. [] ^[1 Signed X - Title: Date: l CJ - M � FOR DEPARTMENT USE ONLY Application Accepted by Date Area O Z j�447 ' Pit or Grout Inspection Date Final inspection by Date - Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-63854 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 a ' FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY ' DATE MPERM�TNO.INFO EH 13-24IREV.4iA5) i� �/� ' EH 14-28 - ,