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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA L Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Appealth District for a r install the rk madeint nt compliance wr th SanoJoaqu nthe SanCounty OrdinaJoaquin lnclpermit eiebyis e No. 549 for sewage or No. 1862 1862 focwe Ildpuomp and the Rules herein k s and R Regulations of tlhe Sanapplication Joaquin Local Health District. AAII r j7� p� /� �5 / v �Q N WAY City LA !d1 R6�f Lot Size SCJ y 1-37 PM Job Address �t � /�J'j fJ f �,( Q r y/7PJ- 1 • n OL-M Address s� Phone V`� 9^2 Owner`s Name /gyp Contractor 44 Address License No. Phone TYPE OF WELL/PUMP, NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. i f Well Casing Type of Casing Specifications ¢n ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy yp "1 1'1 Public F1 Other Cl Delta Depth of Grout Seal Type of Graut I I Irrigation —Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION [1 REPAIRlADDITIDN [ I DESTRUCTION alvailablelwthine200 feet.stm itied if public sewer is Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms — Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 9 Type/Mfg Capacity No. Compartments 2 PKG. TREATMENT PLT. ❑ Method of Disposal P/RT Distance to nearest: Well Foundation Property Line _4 LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 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 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 or sub-contracting signature cartifies the following: "I 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 rttys for 11 Yf i ' pact Complete drD awing on reverse side. �r � r 7 Signed X� Title: Date: 7 FOR DEPARTMENT USE ONLY Application Accepted by r' Date Area Pit or Grout Inspection by Date Final Inspection by;4�� 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, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASA RECEIVED BY DATE PERMIT NO. 1NF0 + EH 1324(REV.1/A 5) EH 14-26