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APPLICATION FOR.PERMIT �.> SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. NAZELTON AVE., STOCKTON, CA Y\ Telephone (209) 46676781 Y\ PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Y application is permit to construct and/or install the work herein described. of the San Joaquin Application is hereby made to the San Joaquin Loc af Health District for a p um and the Rules and Reg made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllp p Local Health PM �J d� J City rfl� Lot Size Job Address i c(ted Cit P( tlddmss sewtM & _ Phone Owner's Name } Z -- j{ License No. Phone ((L r Address Contractor WELL REPLACEMENT C1 DESTRUCTION ❑ � TYPE OF NEW WELL ❑ OTHER El SYSTEM REPAIR El t PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE _�— p17SISUMPS DISTANCE TO NEAREST: SEPTIC TANK — AGRICULTURE WELL OTHER WELL j # FOUNDATION --- INTENDED USE TYPE OF:WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing �} en Bottom ❑ Manteca Dia. of Well Excavation k A� ❑ industrial Q;Op Specifications if" Type of Casing F� .,.-.-�- T �- -� •�." .,. Type of Grout ❑ domesticlPrivate Gravel Pack ❑ Tracy Depth of Grout Seal f ❑ Public C] Other t❑ Delta _ Surface Seal instalied by I I Irrigation --Appro. Depth l I Eastern I State Work Done — I ! Repair Work Done ❑ Type_of Pump --�— N.P.Sealing Material atop 561 I Well Destruction ❑ Well Diameter Filler Material IBelow-50 i-� ` Depth available,within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAIRIADDITiON f I ; DESTRUCTION; No septic system permitted if public sewer is Installation will serve: Residence Commercial_ Other Number of living units: Dumber of bedrooms ` - Water table depth Y Character of soil to a depth of 3 feet: No. Compartments ❑.. Type/Mfg Capacity_ y�\ SEPTIC TANK Method of Disposal PKG. TREATMENT PLT. ❑ - - Pro art Line Distance to nearest: Well Foundation P Y f1 s & Length of lines LEACHING LINE ❑ No. Total length/size rFoundation Property Line r FILTER BED ❑ Distance to nearest: Well s Size Number SEEPAGE PITS i I * Depth u undation"'Fo2 Property Line SUMPS L� , Distance to nearest: Well �. 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, 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 f manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature employ any person in such i certifies the following: "I certify that in the performance of the work for which this permit is issued,!shall employ persons subject to workman's compensa- tion laws of California." i The applicant must call for all re ired ' speclions. Complete drawing on reverse side. Title: Date: Signed X { ' FOR DEP4.RTMENT USE ONLY t ` _ Date Area Application Accepted by c ' DaFinal Ion by !_Jnspect l Date Pit or Grout Inspection by - Additional Comments: ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 ElTracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 CK RECEIVED BYjOA7E PERMIT'N0. FEE AMOUNT DUE AMOUNT REMITTED CASH INFO r.EH 13-241REV.i/Ksi �° 4_3's [jQr 'bl'Jl EH 14-26