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3. -APPLICATION FOR PERMIT SAN JOAdVIN•,LOCAL HEALTH DISTRICT 1601 E.,.HAZE':-TON AVE., STOCKTON, CA 7 Telephdsne (209) 466-6781 _ PERMIT EXPIRES 1.YF-AR FROM DATE ISSUED (Complete in Triplicate) ition is .This ca Application is hereby made to the San Joaquin Local Health District for a sewage or,No. 1$6'1 for well pump and the Rules and Regconstruct and/or install the work herein ulations of he Sang Joaquin " made in compliance with San Joaquin County Ordinance Na.549 g < Local Health District. ii l� L u L � [ s - ist Size ' n PM i Job Address , �. �l Address % �' �= �- 'G�" r ' Phone Owner's Name _ Contractor's !Name �a �" �S r��Lcense No. � �J Zi�`- � �; `'�+ Phone 7�� I� �e TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION I' SYSTEM REPAIR ElOTHER El DISTANCE TO NEAREST: SEPTIC TANK ,/ SEWER LINES o� DISPOSAL FLD//-]CPROPLINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS cr�� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing h ❑ Industrial P'Open Bottom ❑-Manteca Dia. of Well Excavation ❑4• omestic/Private El Gravel Pack Ll Tracy Type of Casing—sl:5 Zj Specifications _ El Public El Other ❑ Delta Depth of Grout Seal Type of Grout i ❑ Irrigation --Approx. Depth F Eastern Su a Seal Installed by t Repair Work Done ❑ Type of Pump Gv H P State Work Done Well Destruction ❑ Well Diameter Sealing Ma eri Itoo 50`1 Depth Filler Material (Below 501 Ir TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ aNailablelWithin e200 feet.) if pubic sewer is 3 Installation will serve: Residence Commercial Other . Number of living units: Number of bedrooms Water table depth Character of soil to a.depth of 3 feet: No. Compartments SEPTIC TANK ElType/Mfg Capacity Method of Disposal PKG. TREATMENT PLT. Q ` Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS [DDistance to nearest: Well Foundation Property Line DISPOSA--PONDS f.^❑- 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. 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 parson 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 required inspections. Complete drawing on reverse side. 't Date: Signed Title: ,-r OR DEPARTMENT USE ONLY �� r�y ` Data e 2 �=�r` as Accepted x- Application Ated by ` °` �jd 'bate��(1 Pit or rou Inspection by Date Final Inspection by r 7. Additional Comments: c ❑ Stk 466-Ml ❑ Lodi 3&9 3611 ❑ Manteca 8x3 7104 ❑ Tracy 835-6385 s Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CAg ?� t13 u• " FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE + EH 13-24(REV.101831 INFO - � S I• g3 �/� �� b~�O,` EH 14-25