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AW__ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 160f E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) is cation de to the San Joaquin Loc No.549 for sewage or Eand/ort to construct herein No. 1862 for we Ilpump and the Rules and Regulations of lthe Sant Joaquin Application is hereby ma made in compliance with San Joaquin Cou ty Local Health District. # jXeL �` //�� City Lot Size PM X Job Address Phone Address Owner's Name Contract- Address License No.� Phone NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION V TYPE OF WELL/ P: SYSTEM REPAIR L3 OTHER ❑ PUMP INSTALLATION ❑ " SEWER LINES �_�-- DISPOSAL FLD, PROP. LINE { DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL— INTENDED \ FOUNDATION AGRICULTURE WELL k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .Dia. ofWell Casing ElIndustrial L3Open Bottom ❑ Manteca Ria. of Well Excavation Specifications T e of Casing ❑ Domestic/Private -0 Gravel Pack L1 Tracy Depth of Grout Seal Type of Grout — k l Public Cl Other 171 Delta _ I 1 Irrigation �_Approx. Depth I 1 Eastern Surface Seal Installed by Work Done i H.P. 1 Repair Work Done L2 Type of Pump Sealing Material (top 50') � Well Destruction ❑ Well Diameter Filler Material {Below 501 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1l REPAIRIADDITlON I 1 DESTRUCTION Ilvailabpe+w thin 200 feetc system .) 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: 4- No. Compartments [� ❑ Type/Mfg Capacity 1 " SEPTIC TANK Method of Disposal i PKG. TREATMENT PLT. ❑ Property Line Distance to nearest: Well Foundation a � . Total lerigth/size LEACHING LINE ❑ No- & Length of lines ,Property Line � FILTER BED ❑ Distance to nearest: Welk Foundation Size Number SEEPAGE PITS I I Depth_ Foundation Property Line SUMPS D Distance to nearest: Well DISPOSAL PONDS ❑ certify that will be done in accordance with San Joaquin county ordinances, state laws, an 1 hereby I have prepared this application and that the work 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 worts for which this permit is issued, l signature s all not 5 employ any person in such manner as to become subject to workman's compensation law s of California." Contraceonslsub'ct toring or bworkman!scompensa- certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ p 1 I tion laws of California." The appli�.jn, mu tail fdr all d 4ed inspect .Complete drawing on reverse side. , � — ! Title: Date: Signed FOR DEPARTMENT USE ONLY Date 2—r W Area Application Accepted by l Date Date Final Inspection by Pit or Grout Inspection by � Additional Comments: / } ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 104 ❑ Tracy 835-6385 I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95291 CK DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY INFO ?I[ /V/ 4;2 �- V �� r EH 13-24(REV.+/N5] ��1`66 EH 14-28