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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 3 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED - (Complete in Triplicate) App is cation is madlecntcompfiance with Sano)Joaquin county ordinance No.549 for sewage or the San Joaquin Local Health District for a permit 1862 far welUpump and the Rules and IR Regulations of the San l Joaquin I Local Health District.) LL/,�[ �+ 1 ' f G �r City : 1 Lot Size PM _11--rob.ob"Address ,'` yfr f�l 171 Address Phone Owner's Name i 4 Contractor l, ��©SS�. 11.� _Address scense No. C1D1Phone 27 TYPE OF WELL/PUMP: NEW WELL Ll WELL REPLACEMENT ❑ DESTRUCTION ❑ ! * PUMP INSTALLATION f5 - "' SYSTEM REPAIR ❑ OTHER ❑ n- DISTANCE TO NEAREST: SEPTIC TANK JdA SEWER LINES DISPOSAL FLD. 70 flOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I7 Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of WeII Casing N, omestic/Private ❑_Gravel Pack ❑ Tracy Type of Casing e Specifications 1-1 Public C1 Other ❑ Delta + Depth of Grout Seal 0 Type of Grout 1 I Irrigation %3V.Appfou: Depth I ] Eastern S urfa&e Seal Installed by Repair Work Done LJ Type of Pump 6+ 14 H.P. II` State Work Done Well Destruction ❑ Weil Diameter Sealing Material itop 501 Depth Filler Material iBelow 50'1 W TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION I I iNo septic system permitted if public sewer is r^ available within 200 feet.) 4. A 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 SEPTIC-TANK _ ❑ Type/Mfg k j- Capacity No. Compartments r PKG. TREATMENT PLT. ❑ Method of Disposal Distance to,riearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED' ❑ Distance to nearest: " Well Foundation Property Line SEEPAGE PITS 1 I: Depth Size Number SUMPS L-1 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 r 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." r fi The applicant must call for all required ins ctions. Complete drawing on-reverse side. 4 Signed X Title: Date: u 10^- OR N LY Application Accepted by Date Area Pit or Grout Inspection by * Date Final Inspection by Date I Additional Comments; �.�1'r o t ❑ Stk 466-6781 d Lodi 369-3621 ❑ Manteca 823-7104 ❑ Traty 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t - -FE�Y! UNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT NO. INF r.EH 13-24 1REV.s/H sY `� O� , t./� "v [2 f _ J EH 14-29