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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED (Complete in Triplicate) quin Local Health District for a permit to construct and/or install the work herein described. This application is Application is hereby made to the San Joaor No. 1$62 for we111pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No. 549 for sewage y Local Health District. City#eLot Size PM Job Address �j(f — e,—W Address � Phone Owner's Name ep �� g Phone Contractor Address 0 License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS E INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications " C1 Domestic/Private ❑ Gravel Pack LI Tracy Type of Casing p FI Public ❑ Other Delta Depth of Grout Seal Type of Grout - I E Irrigation --Approx.-Depth-1.) Eastern- _a_T Suriace_5eal Installed by Repair Work Done ❑ Type of Pump —.�-- H.P. -State Work Done Sealing Material Ito 5011 Well Destruction � Well Diameter � 9 p � "1 Depth Filler Material [Below 501' \ TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION t I DESTRUCTION I I (No septic systeshin m permitted if public sewevisavailable \ h Oter y Installation will serve: Residence— Commercial— Number of living units: Number of bedrooms Water table depth _ Character of sail to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg ` PKG. TREATMENT PLT. D . Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L1No. & Length of lines Tota! length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r .�...-_•� _._�,......�----�.�„�.-..rte._ � SEEPAGE PITS { l Depth Size Number i 4 'V SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i. 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 i ued, !shall not employ any person in such manner as to become subject to workman's compensation taws of California."Contractor's hiring or sub-cont acting 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 work an's compensa- tion laws of California." The applicant I or requir ions. Complete dAawing-on rev. rs ,aide. u Title: �� _ Date: Signed X DEPA ENT USE ONLY I Date ` Area Application Accepted by Pit or Grout Inspection by Date Final Inspection by Date I Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621, ❑ Manteca 823 7164 ❑ Tracy 835-6385r 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 a i CK ; FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT NG. .,EH 13-24(REV.I/H 5) INFO &CvqO 1%= '17 EH 14-26