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APPLICATION FOR PERMIT N�W"� ��QQ SAN JOAQUIN LOCAL HEALTH DISTRICT "`�r � 1601 E. HAZEL T ON AVE., STOCKTON, CA N a \�M Telephone (209) 466-6781 kN PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is e or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewag ! Loc Health District. Job Address City 0A Lot Size PM �_..� G � "Owner's Name Address Phone 6 7 s Contractor Address License No. Phone TYPE OF WELL/PU NEW WELL ❑ WELL REPLAC MENT ❑ DESTRUCTION D PUMP INSTALLATION ❑ SYST REPAIR D OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SE ER LINES DISPOSAL FLD. PROP. LINE FOUNDATION " ' -- 'AGRI ULTU WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing FCasing- 0 Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing p I'l Public Cl Other 71 Delta pth of Grout Seal Type of Grout ti I�.Irrigation Approx. Depth I 1 Eastern Su a Seal Installed by Repair Work Done ❑ Type of Pump H.P. rt State Work Done _ P Well Destruction ❑---Well Diameter Sealing Material Itop 501 r Depth Filler Material IBelow 501 { TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 1 DESTRUCTIO ! (No sepfic'system permitted if public sewer is available within 200 feet.i i Installation will serve: Residence_ Commercial .Other R 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size e FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ci Distance to nearest: Well Foundation Property Line Ir 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, an 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." The applicant must call for all r q ed inspect' s. Complete drawing on reverse sid i Signed.X Title: Date: A/4 7 FO EPPA-RTMENT USE ONLY (� Application Accepted by _ `'t`^ ' +� s— Date �'�� 6 Area�`—� - t Pit or Grout Inspection by Dates Final Inspection by Date Additional Comments: rie I o } e( 23 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638 Applicant - Return all copies to: Environmental Health Permit/Services 1601�E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FEE AMOUNT DUE AMOUNT REMITTED CK 7�N RECEIVED BY DATE PERMIO. I INFO Q.r{}(� EH 13.24(REV.i i H 51 �.7� i a O EH 14-26