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APPLICATION FOR PERMIT �` s SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Appit and/or install the work n describe . This cation is madlecaon is inti ompliance weieby ith Sanade toJoaqu nthe San Coungty Ordinance Joauin lNth District for a o.549 for sewage or permit No. 1862 forcwe l//pump and the Rules and'R gulations of the San Joaquin Local Health District. Job Address ✓ A4C44e-Z�3 Ci N Lot Size 66 r� PM Owner's Name Address 1�3 �` � Phone Ie3® ' Phone Contractor �f Address License No. 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 OTkfEft WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR N SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing Specifications F1 Public ❑ Other elta Depth of Grout Seal Type of Grout — I I Irrigation ___Ap epth I I Eastern Surface Seal Installed by - Repair Work Done ❑ e of Pump H.P. State Work Done_ Well Destruc' ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION t I DESTRUCTIOI (No septic system permitted if public sewer is available within 200 feet.) 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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 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." Thet must or a req - inspec'ons. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted byDate ` l . Area Pit or Grout Inspection Date Final Inspection by Nc:,6 J��11;e Additional Comments: El Stk 466-6781 Lodi 369-3621 ❑ Mante r 823-7104 ❑ Tracy 835-6385 �od Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. h INFO \\ IG ^( Cn \ + EH 13-24(REV.sins) �,U� S� ,Uf J ^�� ` r!C) 1. EH 14-267/ � 3