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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED u (Complete in Triplicate) i aquiistrict for a permit to construct and/or install the work herein described. This applicatio Application is heleby made to the San Jon is n Local Health D 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 Local Health District. � City 'Lot Size � PM Job Address .—t,L Address i✓ Phonee Owner's Name 6KT Q� � fl � Phone Contractor 7^ Address License No. �V WELL REPLACEMENT ❑ DESTRUCTION ❑ -�—�---�--FYPE-OF WELL-/PUMP:.— .. ..M. ,NEW,WELL.❑ .,µ ._. OTHER ❑ f PUMP INSL1TALLATION SYSTEM REPAIR ❑ SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK , PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL >j�[i f, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing �/�f ' ❑ Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation ol T e of CainS Specifications .❑ Domestic lPrivate ❑ Gravel Pack El Tracy yp g1 ; i 1`Public ❑ Other n Delta Depth of Grout Seal Type of Grout 1 I Irrigation _.-Approx. Depth I 1 Eastern Surface Seal Installs y 'Repair Work Done ❑ Type of Pump H.P. State Work Done - —Well Destruction ❑ Well Diameter Sealing Material atop 50'1 Depth 'Fillet Material i18elow 501 TYPE SEPTIC-WORK: 'NEW INSTALLATION i.l REPAIR/ADDITION DESTRUCTION I I alvailabperwithine200 feepermt ped if public sewer is Installation will serve: Residence vo, Commercial"-Other,.." Number of living Units: Number ofbedrooms, 3 I k Water table depth Character of soil to a depth of 3 feet: :._.,�G✓1 'f Y t a. Capacity t No.,Compartments SEPTIC TANK ❑ Type/Mfg +.. PKG. TREATMENT PLT. ❑ a _� r ,.,, _Method,of,Disposal Distance to nearest: Well Foundation Property Line A, I LEACHING LINE s No. & Length of lines g Total length/size FILTER BED F] Distance to nearest: 4Well' Foundation Property Line_. _.— . SEEPAGE PITS I I Depth Size _ Number I SUMPS [l 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 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 quired inspections. Complete drawing on reverse side. Title:1 L Date: t Signed X ,r.- FOR DEPARTMENT USE ONLY iDate Area Application Accepted by Date Final Inspection by Date Pit or Grout Inspection by • Additional Comments: ❑ Tracy 835-6385 ❑ Stk 466-6781 C1 Lodi 369-3621 El Manteca 823-7104 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r k FEE AMOUNT DUE AMOUNT REMITTED ASR RECEIVED BY DATE PERMIT NO. F INFO ; EH 14-25 l