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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) k rk herein described. This made in Application om i ante with Sanothe San Joaqu n coungty Ordinance No.549 for sewage or permit No 1862 for well/and/or pump ainstall nd the Rues and Regulations of the Sanapplication Joaquin P ! Local Health District. - r /' [ City �/ 6(,/Z -tot Size ! PM J—zMb Address 3z �` r g[4Q t�f& � /Le Owner's Name f"� ��^� "" Address Phone �1 `` i Contractor K P/,p0e�0 Address -- License No. Phone TYPE OF WELLIPUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE s FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca ��,} Type of CasingSpecifications r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy - FI Public Cl Other Ll Delta Depth of Grout Seal Type of Grout _ 11 Irrigation --Approx. Depth I i Eastern Surface Seal Installed by - Repair Work Done LlType of Pump H.P. State Work Done_ Well Destruction [y Well Diameter Sealing Material Itop 501 C� Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIR/ADDITION l 1 DESTRUCTION, INo septic system permitted if public sewer is , available within 200 feet.I Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No:�,& Length of lines k Total length/size k FILTER SED ❑ Distance o neatest_ Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i ll be done in I hereby certify that I have prepared this application and that the work wiccorda ce with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner o agent's signature certifies the following: "I certifyAhat-in the performance of the work for which this permit is issued, I shall not employ person in such nner as to became sub ect to workman's compensation laws of California." Contractor's hiring or sub-contracting signature ce ' es the following: "I certif that n the perform c of the work for which this permit is issued, I shall employ persons subject to workman's compensa- ` ti laws of California." e tieaa ust call all re -red pecti Comp pte drawing on r%vJerrss'e side. a/!wz ned X Dat FOR DEPARTMENT USE ONLY Application Accepted by L z,�e, Date 21 — Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi -3621 0 Manteca 823-7104 Cl Tracy 835-6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO —to C1 a.EH U-24(REV.11 A 5Y 00 EH t4-26 1 -