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til. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) This cation is all the work n desr made in corms lance with the Son County ordinance uin lfNo.549 for sewage orealth District for a 't to No, 1862 forcwell/pump atnd the Rules and'Regulations of the San'Joaquin ! made P - cal Health District. r City Lot Size- PM Job Address f u _ Address —f C�1– 1-A ? .4 lh r Phone ^.1 Owner's Name '•° ai 71 Contractor Address License No. Phone TYPE OF WELLIPUMP: IL.NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ w SEWER LINES DISTANCE TO NEAREST: SEPTIC TANK DISPO PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR NSTRUCTION SPECIFICATIONS O Industrial CI Open•Bottdm -- ❑ eca Dia. of Well Excavation Dia. of Well Casing Type of Casing Specifications ❑ Domestic/Private ❑ Gravel Pace ❑ Tracy YP g Type of Grout I 1 Irrigation Approx. Depth { 1 Eastern I'1 Public F1 r t Cl Delta Depth of Grout Seal r Surface Seal Installed by �- Repair Work one ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 -- ' TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUC77 afvo septicailable sy t m permitted if public sewer is Installation will serve: Residence— Commercial_.Other Number of living units: Number ofbedrooms Character of soil to a depth of 3 feet Water table depth SEPTIC TANK ❑ Type/Mfg.. Capacity. No. Compartments i PKG. TREATMENT PLT. ❑ 1 Method of Disposal 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 I SEEPAGE PITS I l Depth :! Size Number SUMPS L-1 Distance to nearest: Well Foundation Property Line N DISPOSAL 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'C rules and regulations of the San Joaquin Local Health District. J rk for which this permit Home owner or licensed agent's signature certifies the fallowing: "'I certify that in the performance of the woissued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California.'"Contractors 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." ;1 j The applicant must call for all requiredrin ctions. Complete drawing on reverse side. _ E S 62 igned X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted Date Final Inspec by Area u Date Pit or Grout Inspection by Y I on by Date r r. Additional Comments: 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I rEEE AMOUNT DUE AMOUNT REMITTED µ RECEIVED BY DATE PERMIT NO._ S } +.EHt3-24MEV.iK5) INFO 3 '^} .�.-J'✓ � ` � /� � I EH 14.26