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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE, STOCKTON, CA a� ` Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED it (Complete in Triplicate) cons,tru all the work . This cation is i Application is heiebyNmhdSa�othe Joags nnCou Joaquin OLdinalnce No.549 for sewage or permit No. 1862 forcwell/dpump end the Rules and IR Regulations of the Sanr Joaquin made in compliance Local Health district. I / � .�p C City �— Lot Size PM Job Address 1 O f� Phone 'Address Owner's Name� 11 sem' ,/, / License No.�_�-Phone iWr Contractor iTe ✓� Address l � • ~ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ � PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' �PROP:`LINE '"��pISPOSAL FLD"'•'""' DISTANCE TO NEAREST: SEPTIC TANK ______SEWER L1NE�''�� " "� ' FOUNDATION.- .AGRICULTUAE.WELL. —:OTHER:OTHER WELL - - - - -w-PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications 13 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Depth of Grout Seal Type of Grout'�f' FI Public n"Other f 1 Delta _._Approx. Depth I 1 Eastern Surface Seal Installed by I I Irrigation State Work Done Repair Work Done ElType of Pump H.P. Well Destruction ❑ Well Diameter Sealing Material Itop 501 . s Q r �_s*y (\ Depth Filler Material (Below 50'I -�f TYPE OF SEPTIC WORK: NEW INSTALLATION I'l REPAIR/ADDITION l I DESTRUCTION availablelc system within 200 feet.) if public sewer.is .. Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: F �rNo. Compartments { 'k Capacity f SEPTIC TANK ❑,i Type/Mfg f r Method of Disposal PKG. TREATMENT PLT.❑ c " Distance to nearest: Well Foundation Property Line + i LEACHING LINE ❑ Na. & Length of lines Total length/size f FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I i Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ nd that the work will be done in accordance with San I hereby certify that{ have prepared this application aJoaquin county ordinances, state laws, and, rules and regulations of the San Joaquin Local Health DFstrict. 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•of sub-contracting signature certifies the following: 111 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 qu'red inspections. Complete drawing on reverse side. p_ Signed X Title: Date: FOR DEPARTMENT USE ONLY Date '-' Area I Application Accepted by C Pit or Grout Inspection by Date � Final Inspection by Datea � t Additional Comments: 9 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 { Applicant- Return all copies toTEnvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,-Stk., CA 95201 FEE CK RECEIVED BY DATE PERMIT'NO. AMOUNT DUE AMOUNT REMITTED CASH INFO c (/� F �] �.EH 13-24 4REV.i i A 5) *V f4 - 'C c ! f EH 14.26