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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` ! 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1`YEAR FROM DATE ISSUED �I (Complete in Triplicate) Application is hereby made to th'e San Joaquin Local Health District for a permit to construct-and/or install the work herein described. This application is or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage I Local Health District. Job Address 15717 City Lot Size PM COOwner's Name /_5 t✓ CeZAddress Phone r Contractor�- Address License No. Phone TYPE OF WELL/PUMP:. NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ~❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications f"1 Public ❑ Other 1-1 Delta Depth of Grout Seal Type of Grout — I i Irrigation Approx. Depth I I Eastern r Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Stop 501 Depth Filler Material (Bel w 50') TYPE OF SEPTIC WORK: NEW INSTALLATION {.1 REPAIR/ADDITIO DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) " 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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ r, Method of Disposal Distance to nearest: Well foundation Property Line LEACHING LINE ❑ No. & Length of lines Total ldngth/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i'I 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'adc`ordante with Sari Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. i Home owner or licensed agent's signature certifies the fallowing: "t 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." t - 1 = The applicant must call for all-required inspections. Complete drawing on reverse side. Vp XSigned X Title: Date:FOR DEPARTMENT USE-ONLY. . . Application Accepted by Date " Area Pit or Grout Inspection by Date f=inal Inspection by Date 0 U Additional Comments: ��7/ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-fi385 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 CASH RECEIVED BY PATE PERMIT NO. INFOOr + EH13-24 MEV-1/H 51 EH 14-26