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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL�HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES'1 YEAR FROM DATE ISSUED t tr (Complete in Triplicate} his is nd/6r install the work herein described. T Application.is hereby made to the San Joaquin Joaquin n County ordinance No.District549 for sewage or 1No. 1862 forcwelllpump and the Roles and Regulations of he Sangcation J aquin i made in compliance with q Local Health District. ` t{ 4. 41, c' x " oli y., Q/ 1 City Tyli#[C Lot Size , Job Address r Ltu{ ;",Je" 1 ,< 4 Ph A. . .. . m. one Owner's Name r. tY 8�� Phone ! i� License No. ' .-- � Contractor JA 6.A.v Address TYPE OF WELL/PUMP: " f NEW WELL ❑ WELL REPLACEMENT RUCTION ❑ ❑ 1 DESTt PUMP INSTALLATION L1PROP. LINE SYSTEM REPAIR ❑ r OTHER Q SEWER LINES DISPOSAL FLD. DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL �, ) INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Open Bottom ❑'Manteca Dia of Well Excavation ❑ Industrial " k .3 �-Type � of Casing - -Y Specifications- --°-- - _ ❑ DomesticlPrivate...:. E1 Gravel Pack--�-- 0 Tracy, Type of Grout ❑ Other f❑ Delta Depth of Grout Seal ❑ Public Surface Seal installed by EJ Irrigation --Approx. Depth ❑ Eastefn State Work Done Repair Work Done ❑ Type of Pump Sealing Material {top 50'} Well Destruction ❑ Well Diameter _ .De`ph Filler Material (Below 50'1 � . DESTRUCTION LlTYPE OF SEPTIC WORK: NEW INSTALLATION JV ARS pIT101V E3aNailablelwithin eper ied ifpublic sewer is 200 feet.) w . r Jd Commercial _Otherr t i\ `rXlti�> Installation will serve: Residence - Number of living units: Number of bedrooms Water table depth.-- t Character of soil to a depth of 3 feet: f- ' T" a/Mf i Capacity J.Z No. Compartments SEPTIC TANK . ,.% i yp g Method of Disposal PKG. TREATNIENT.PLT. ❑ I , X b' p Foundation - Property Line Distance to nearest: Well— O�— � No. & Length of"lines Total length/size !�O r LEACHING LIVE Ey 014 r � �D Foundation Property Line or FILTER BED ❑ Distance to nearest: Well / i Numer--�. - ",-� � " b -,.� • SEEPAGE PITS---L91--Dep th-- - - Size p0 y Line � SUMPS C9 Distance to nearest: Well�-- Foundation 1ve' Propert I DISPOSAL PONDS ❑ ' _,.,_,_�,,.�..x-,..-.--.,...--mss'-..:..--�.:�.,.•.�.�.-_ .� . ..-.-.,-.... ,-..„. .-..,.- I hereby certify that 1 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. Home owner or licensed agent's signature certifies the fdllowing. "1 certify that in the performance of the work-forwhich;this:,permit is issued, I signature shall not , employ any person in such manner as to become subject to workman's compensation laws of California."employ Contractor's subject t workman'sring or compensa- certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ p -_ , tion laws of California." d'r .The applicant must cal for all required inspections. Complete drawing on reverse side. � Title: Date: � , a Signed s R DEPARTMENT U5E"ONLY s Date Area Application Accepted by i Pit or Grout Inspection by Date Final Inspection by f Additional Comments: ❑ 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,iStk.,"CA 95201 CK# RECEIVED BY DATE PERMWNO. FEE AMOUNT'DUE AMOUNT REMITTED .- CASH (� INFO ie f� k—Z S ��^IO(, + EH 1324(11W.3/a 5) 1- o-00 EH W26 _�- :..... .. ..-