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APPLICATION FOR PERMIT . � SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r install the work herein , This cation is Application is hereby made a to the nJoa Counquin ty Ordinalnce No.549 for sewage ealth District for a or INo 1862 for t to cwe well/pump and the Rules and Regulations of he San l Joaquin made in compliance w Local Health District. �3 3 City Lot Size PM Jab Address � T `� Address -2- / Phone �wner's Nano Contractor �Adddfess License No. Phone TYPE OF WELL/PUM NEW ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION L3SYSTEM REPAIR ❑ OTHER .❑ NCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PROP. LINE UNDATION AGRICULTURE WELL ER WELL PITS/SUMPS"'� `INTENDED USE TYPE OF WELL AR NSTRUCTk)N SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ ca ell Excavation Dia. of Well Casing T e of Casio Specifications El Domestic/Private ❑ Gravel Pack L7 Tracy Yp g Type o Grout i`I Public ❑ Other (1 Delta Depth of Grout Seal I I Irrigation Approx. Depth 11 Eastern Surface Seal installed by Repair Work Done Type of Pump H.P. State Work Done— Repair Well Des Ion ❑ Well Diameter Sealing Material (top 50'I Depth Filler Material (Below 5131 TYPE OF SEPTIC WORK: NEW INSTALLATION l:l REPAIRIADDITION i l DESTRUCTIONN (Nailabpticle system in rent}ed if public sewer is Installation will serve: Residence__ Commercial— Other Number of living units: Number of bedrooms y .-,,,� •- - •r 1lVater'table depth Character of soil to a depth of 3 feet: I Capacity No. Compartments SEPTIC TANK [73 Type/Mfg `h\ ❑ Method of Disposal PKG. TREATMENT PLT. Pro ert Line ° Distance to nearest: Well Foundation P Y LEACHING LINE ❑ No. & Length of lines Total length/size `l FILTER BED ❑ Distance to nearest: Well Foundation Property Line "] SEEPAGE PITS I-1 Depth Size Number SUMPS Irl 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 �jrules and regulations of the San Joaquin Local Health Di§trict. v "I certify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: employ any person in such manner as to became subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature certifies 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 must call fpr all requ' d inspections. Complete drawing on reverse side. Zz � l Title: Y' Date: �^ Signed d FOR DEPARTMENT USE ONLY � ��_� Date Area 4 Application Accepted by Q� Pit or Grout Inspection by Data Final inspection by Date J 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 ^ CK FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CASH +.EH 1 3-24(REV.t EH 14.26 A„