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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ll the work Application is hereby mh a tothe San Joaquin Joaquin County ordinance Local le No.549 for sewage alt orland/ort to construct rNo.1862 for welllpump anherein d the Rules and Regulations of he San'Joaquin made in compliant Local Health District. Lot Size PM Job Address Address J4-3,1 « Owner's Name }iy Y � J d L E / Phone r Phone r d� License No. Contractor's Name DESTRUCTION ❑ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ PUMP INSTALLATION O SYSTEM REPAIR Er OTHER :1 SEWER LINES DISPOSAL FLD. PROP. LINE CP DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS FOUNDATION �- AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL s PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Wel! Casing ❑ Industrial C1 Open Bottom El Manteca Dia. of Well Excavation Type of Casing - ❑ Public ❑Other ❑ Delta � Specifications ❑ Domestic/Private L1 Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout _—Approxi Depth Eastern S urface Seal Installed by ❑ Irrigation State Work Done Repair Work Done ❑ Type of Pump H.P. Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below, 0'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 0. REPAIR/ADDITION ❑ DESTRUCTION ❑ alvailablleiwit in 200 m Pe f et.) if public sewer is Installation will sere: Residence— Commercials Other N Number of living units: Number of bedrooms _ Water table depth s Character of soil to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg ' Method of Dispo§al PKG. TREATMENT PLT. ❑ `47 Distance to nearest: Well " Foundation Property Line Total length/size LEACHING LINE ❑ No. & Length of lines Property Line FILTER BED C1 Distance to nearest : Well Foundation 1 ❑ Depth Size Number SEEPAGE PITS SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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. Nome owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, !signature shallnot employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's t workman sub-contractingring or s ompensa certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons tion laws of California." The applicant must C L%II for required inspections. Complete drawing on re;v7e side. / �I tea. Date: N _ �—1 Title: Signed _ - FO DEPARTMENT USE ONLY Date Area Application Accepted by { Dat Pit or Grout Inspection by !v Date Final Inspection by 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 C RECEIVED BY DATE PERMIT"NO. FEE AMOUNT DUE AMOUNT REMITTED c lJ +EH 13-24(REV.10183) INFO S. .fl p R -77.5 EH 1428