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k t APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) t and/or rk . This Application is hereby with San the San Joa u n counguin Local ty Ordinance Nth District for a o.549 for sewage or't to No. 1862 forcwell pump install nd the R'les and herein Regulations of the Sancation is Joaquin made in compliance with S q Local Health District. �J Y� � f��` City Lot Size Job Address / .� ' ! � Phone (94 Owner's Name �-- " � I Phone F �+,�4 �� License No. --- Contractor Address, DESTRUCTION ❑ TYPE OF WELL/ UMP NEW WELL E-1WERE LACEMENT 11OTHEA C3 PUMP INSTALLATION D' SYSTEM REPAIR Cl DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE -- — AGRICULTURE WELL OTHER WELL— PITSlSUMPS — FOUNDATION `----- 1� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia- of Well Casing C] O Bottom Ll Dia. of Weli Excavation El Industrial pen Specifications Type of Casing---- [1 asing_ 1 �] Domestic/Private I�i Gravel Pack LI Tracy Type of Grout .--- Other h Delta Depth of Grout Seal ["1 Public — I 1 Irrigation Approx. Depth 1 1 Eastern Surface Seal Installed by H.P. State Work Done _ Repair Work Done ❑ Type of Pump — - i Well Destruction ❑ Weil Diameter Seating Material (top 501 Depth _ Fllle: Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 RE.PAIR =,DDITION DESTRUCTION I i available within system m rented 7sewols Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms a_ Water table depth Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK ❑ Type/Mfg _ Capacity — Method of Disposal PKG, TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line / No. & Len Length of lines ___ r+ �/ �Total lengthlsize / LEACHING LINE g _— �U f FILTER BED L] Distance to nearest: WeII� — Foundation�_� Property Line Number SEEPAGE PITS I l Depth Size — —� --- — f O SUMPS Ll Distance to nearest: WellFoundationForrndation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will Le 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: "l certify that in the performance of the work for which this permit is issued, I shall not signature employ any person in such manner as to become subject to workman compensation laws of California."emploContry personslsubjectring rt workman's compensa certifies the following: "I certify that in the performance of the work for which this permit is issued, i shat!employ p tion laws of California." The applicant us tali forired inspections. Complete drawing on reverse side. Title: �� Date: Signed X FOR DEPARTMENT USE ONLY Date Area Application Accepted by — Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 D Lodi 369-3621 ❑ Manteca B23-7104 d Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK RECEkVED BY DATE PERMIT NO. AMOUNT DUE AMOUNT REMITTED CASH INFO ,l( + EK 13-24 IREV.t/n 5) EK 14-26