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f r M5 r 4 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES VYEAR FROM DATE ISSUED i (Complete in Triplicate) i Application compliance with e to the San County Ord' 549 for sewage or permit for cwell//pump and the'Rules and'Regulations of he Sant Joaquin made 1n p 10 . C. �\ Local Health District. , +/ s City Lot Size PM Job Address (� I Owner's Name Address /� � r - Phone Contractor ---- Address License No.. Phone TYPE OF WEL PUMP: NEW WELL a WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ ` SEWER LINES DISPOSAL FLD. PROP. LINE F. DISTANCE TO NEAREST: SEPTIC TANK FOUNDATION AGRICULTURE WELL :OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing E3 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Type of Casing Specifications i .❑ Domesticl Private Cl Gravel Pack ❑ Tracy Yp g — t M Public L3 Other P Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx.. Depth t I Eastern Surface 5ealrinstailed by H P_ State Work Done Repair Work Done ❑ Type of Pump I Well Destruction ❑ Well Diameter Sealing Material (top 501 . Depth Filler Material (Below 50'1 i TYPE OF SEPTIC WORK: NEW INSTALLATION V REPAIR/ADDITION 4 I DESTRUCTION l i INailabpti cystithin m permitted it public sewer is avle Installation will serve: Residence Commercial_' Other Number of living units: J— Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK & Type/Mfg CapacityWo� "No.,Compartments PKG. TREATMENT PLT. ❑ � Method of Disposal y Distance to nearest: Well - Foundation—' — Property Line ` t i LEACHING LINE V ,No. & Length of linesTotal length/size i• FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1S - 4 ' r SEEPAGE PITS l I Depth Size Number SUMPS L, Distance to nearest: Well Foundation Property Lune 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 certifies the following: "I certify that in the parfor nee of the work for which this permit is issued, I shall employ persons subject to workman's compensa- I tion laws of Californi ' The applicant all for all require tions. Complete drawing an reverse side. 1 + / Title: Date:t� Signed X FOR DEPARTMENT USE ONLY Application Accepted by kAb Date 2 — ` Area Pit or Grout Inspection by Date Final Ins ction by Data a-�Y t �\ J Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 .�}�awav a-�Lr Applicant.- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE ;AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. EH 13-24{REV.1/y INFO P-7-4--) 5l �. S 6 7+` ` --) 1- EH 14.26 �,J 5