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IV APPLICATION FOR PERMIT .. SAN JOAQUIN LOCAL HEALTH DISTRICT V 1601 F. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Compike in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 forwellplump and the Rules and Regulations of the San Joaquin Local Health District. or install the work herein is Job Address city Lot Size PM Owner's Name ��`-4 Address / �.�K � �� lip h o n a Contractor [� _� , d Address i- TYPE OF WELL/PUMP: NEW WELL ❑ of License No.� Phone "r �T = WELL-REPLACEMENT=❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ _____ _ SYSTEM REPAIR ❑�'�r DISTANCE TO NEAREST: SEP ANK '� OTHER ❑ ` ;SEVIIER.LfNES FOUNDATIO -F •'DISPOSAL FLD. PROP. LINE 'AGRICULTURE WELL OTHER WE INTENDED USE TYPE OF WELL PRO AREA. CONSTRUC ITS/SUMPS s ❑ Industrial ❑ Open Bottom ❑ Man teca CIFiCATIONS ❑ Domestic/Private • o Wei! Excavation Dia. of Well Casing ❑ Gravel Pack ❑ T Type sing l a ❑ Public TY❑ Delta Specifications t ❑ Irrigation 1 Depth of Grout Type of Grout N " rox. Depth E2 Eastern Surface Seal Installed by Repair Work Done ype of Pump H.P._ �Q Well Destr F-1WellDiameter State Work Done (J� Sealing Material (top 50'I Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATIONIliREPAIR/ADDITION ❑ DESTRUCTION ❑ {Na septic system-permitted if public sewer is Installation will serve: Residenceavailable within 200 feet.} Commercial Number of living units: Number of euro Character of soil to a depth of 3 feet: +4s11�f' SEPTIC TANK ElType/Mfg 41lsL Water table depth PKG. TREATMENT PLT. ❑ Capacity No. Compartments) ' / Method of Disposals r Distance to nearest: WellZ Foundation Property Line� ay�L•C� LEACHING LINEi No. & Length of lines a— Q FILTER BED Total length/size ❑ Di0 stance to nearest: Well � Foundation �d Property Line SEEPAGE PITS ❑ Depth `Size - SUMPS + Number , X Distance to nearest` Well 4'5:O Foundation i DISPOSAL PONDS Cl ' , property Line 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.t Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issuedr 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 tion laws of California." Hermit is issued; I shall employ persons subject to workman's compensa The applicant c for required ' pections. Co tete drawing on reverse side. Signed rv�� - Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by [� - Date 2�� Area Pit or Grout Inspection hate r Final Inspection by Additional Comments: 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT NO. k + EH 1324 iREV.1/13 5) EH 14-26 !!