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F C,/ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE`TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is ereby madethe Joaquin Local Health is cation made in compliance with SanoJoaqu nnDistrict County 0 d nance No.549 for sewage or permit construct No. 1862 forwell and/or pump install nd the Rules and R gulations of the Sanl Joaquin Local Health District. J !. 44__s �� ✓`4u �L L� City ize PM- Job Address bza g- ��Y' � /'T� �� — Phone �� ` Owner's Name Address Contractor's Name—/—`e G '2-3-7-3 <!��; r/ Phone f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LkNE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing Ll Industrial 13 Open Bottom El Manteca Dia. of Well Excavation Lk�omestic/Private ❑ Type Pack Q Tracy of Casing Specifications El Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depths ,�❑ Eastern Surface Seal Installed by S Repair Work Done � Type of Pump -fir H.P. State Work Done G W Well Destruction a Well Diameter Sealing Material atop 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No sepeiwtsystem permitted if public sewer isavaC Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 121.1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments C� PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ 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 per h manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the fa wing:"k rtify that in the performance of the rk for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws o toalifornia." The appii ant mu t c or I requir ins pl drawin n rever side. Signed e: FOR DEPARTMENT USE ONLY Date �3—OP-15'—Area / Application Accepted by /Q Pit or Grout Inspection by Dat �Rnleon by ` Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ff AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. + EH 1324(REV.10183) C r EH 1426 !!!