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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA r - Telephone 12491 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) madecartioon Pha�ee w'nh Sanade o the Joaqu n Courcy Ordinauln lHealth District for a nce No.549 far sewage permit to construct and/or install the work herein described. This application is orNo, 1862 fowelllpump nd the Rules and Regulations of the San Joaquin I Local Health District. �S �1ti�O AE �-SA�t1L7 City .5-77�� Lot Size PM Job Address - I Owner's Name K�2it/Oi1l T� S _ Address S,9�n Phone 3—f9 91& Contractor_- � 0 Address ,✓, 4 ®� T License No. L_ �_7d Phone LX`"977 N 171 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171DESTR OTHER 171 , PUMP INSTALLATION F1 SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r_ T e of Casin Specifications "r , El Domestic/Private ❑ Gravel Pack ❑ Tracy Yp g "V F] Public [I Other F1 Delta Depth of Grout Seal Type of Grout I 1 Irrigation _..Approx. Depth I 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 IN I l REPAIRIADDITION l I DESTRUCTION. available within system permitted 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 ❑ Type/Mfg Capacity No. Compartments Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines y Total length/size FILTER BED ❑ Distance to nearest: Well'— Foundation Property Line SEEPAGE PITS I l 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 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 for all required ins ctions. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY p Application Accepted by. Date ? Area C Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 © Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835 6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, S1k., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K R RECEIVED BY DATE PERMIT'NO. INFO �+ LIPil ' +.EH 43-24{HEV.1 i n 51 EH 14-29 �✓