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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEILTON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) t Application is hencbeyNmade to the San Joaquin County OLocalne Health District for a pe 549 far sewage or INoa 1862 for cwellldpump and the Rules and Regulations of the San all the work herein described. This t Joaquin made in Health Di Local Health District- g `(�yuA14 City Lot Size /4G PM Job Address Phone Owner's Name Cr Address ! Contractor Address f License No. d"x Phone ;TYPE OF WELLIPUMP: r. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ fM PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ SEWER LINES DISPOSAL_ FLD. PROP- LINE t DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM EM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial ❑-Open Bottorn i '�D Manteca Dia. of Well Excavation f Type of Casing Specifications 1 ❑ Domestic/Private ❑ Gravel Pack C1 Tracy YP g Type of Grout t l� jr 171 1I Delta Depth of Grout Seal Other Public astern Surface Seal Installed by iI 1 Irrigation — Approx. Depth f - State Work Done— } Repair Work p6ne ElType of Pump H.P. r- Well Destruction ❑ Well Diameter Sealing Material (top 501_.. Ii DepthFiller Material (Below 501 I DESTRUGTION.i I TYPE OF SEPTIC WORK: NEW INSTALLATION �FtEPAIR/ADDITION l available lwthin 200 feet"ed d public sewer is l Y., filstallatrori will serve: _-R'esidence Other t 1 '?! p Number of bedrooms yIE Numbei..ot living .,.,h ,. °� Water table depth - C [. .�. Y k.�';. ' 1 r ff Character of soil to a depth of 3 feet: _ , No. Compartments T e/Mfg � > Capadity SEPTIC TANK yP , Method of Disposal PKG. TREATMENT PLT. ❑ .� ` �T �` la. Foundation. .Property Line — Distance trn Barest: Wei 7 !E1' No. &,Ln th of lines % Total length/size LEACHING LINE g Property Line I FILTER SED [Ipistahce to nearest` Well •i Foundation '•••= Number f SEEPAGE PITS Depth _ Size c Foundation Property Line r ` SUMPS Cl Distance to nearest: Well 1 DISPOSAL PONDS ;,r ❑ ' 1 hereby certify that I have prepared this applicationandthat'ithe work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San,Joaquits`Local Health District: b F 1 Home owner or1icensed age'ni's signature certifies fhd following:"I certify that in the performance of Thea." work for which this permit is issued, t shall not F Fniploy any person in.such manner as to become subject-to warkman's•compensation laws of California." Contractor's hiring or sub-contracting signature certifies she fallowing: '9 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-,0W California, Ivi ( The applicant must call for all wired ' Spec.I S. Complete drawing on reverse side. i �zu:, Title: Date: - S Signed X — : K FO DEP RTMENT USE ONLY U Date `r� Area Application Accepted by / card j Date' Final Inspection by �,-P'• / Date t Pit or Grout Inspection by Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 0 Tracy 535-6365 p Applicant: Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave-,�P.O. Box 2009, Stk., CA 95201 i CK RECEIVED BY DATE PERMIT NO. CASH 'ra" � FEE AMOUNT DUE AMOUNT REMITTED _ - _-_ --— -- ---- - i INFO --�- �..+-EH 1324 1REV.t'i N 51 �) g # EH 14-29 ! I.