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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT l 1601 E. HAZEL T ON AVE., STOCKTON, CA Q , Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) t and/or install the work herein cation is 1 Arnad catio compliance iebywith Sanmade o the Joaquin nJoaquin Local Health District for a County Ordnance No. 549 for sewage or permit No. 1862 forcwelllloump and the Rules and Regulations of he San Joaquin made in co p Local Health District. ` Job Address City of Size PM � ] //'� �� 1' hD(ddress QO2 P f ��-e f �'e - Phone V_4 L2_ Owner's Name Y Contractor � � Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑, WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION D _ SYSTEM REPAIR ❑ e OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL .OTHER WELL (SUMPS N INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION CATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Di e I Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac ' -Type of Casing - Specifications M Public P Other i - Delta Depth of Grout Seal Type of Grout — ` 1 I Irrigation _ Depth. l I Eastern Surface Seal Installed by— Repair y Repair Work Done ype of Pump H.P. State Work Done— Sealing Material (top 50'1 Well Desv n Cl Well Diameter 9 1 � Depth Filler Material (Below 50') + + ^TYPE,OF SEPTIC WORK: NEW INSTALLATION i a REPAIR/ADDITION (.I DESTRUCTION I available�w thin 200 feetstem .) if public sewer is Installation will serve: ' Residence i Commercial_ Other Number of living units: � Number of bedrooms v .. ~Character of soil to agh of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 3. Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE EI No. & Length of lines Total length/size l' FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I l Depth Size Number SUMPS D Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ l I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I rules and regulations of the San Joaquin Local Health District, I 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." 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." I T nt mu t call for all r quired nspections. Complete drawing on reverse side. Q t Date: +� 7 Signed X Title: �d1J FOR DEPARTMENT USE ONLY, Application Accepted by Date' Area-09 4 D;8M23-7104 Final Inspection by Date Pit or Grout Inspection s '1 I Additional Comments:' ��'~ ' C ❑ Stk 466-5781 ❑ Lodi 369-3621 ❑ Mante ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 a FEE AMOUNT DUE AMOUNT REMITTED AS RECEIVED BY DATE PERMIT NO. INFO + EH 13-241REV.1/95l EH 14-26