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APPLICATION,FOR PERMIT S� SAN JOAQUIN LOCAL HEALTH DISTRICT �0 1601 E. HAZE T ON AVE., STOCKTON, CA JA Telephone (209) 466-6781 ��r Q� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �"'`i l (Complete in Triplicate)App an /or install the work n describe .This cation is madlecinti compliance with San Joaquin Counqty Ordinance No.549 for sewage or permit 1862 for we I/pump and the Rules and'R gulations of the San l Joaquin Local Health District. —� City ��C ry Lot Size�` /5 PM Job Address f f { Phone f7 J Owner's Name 0 } Address Contractor Address License No. Phone TYPE OF WELL/PUMP:. NEW WELL CIWELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 1p, SYSTEM REP ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION RICULTURE LL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A A ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. i f Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy pe of Casing Specifications ❑ Public ❑ Other ❑ D a Dep of Grout Seal Type of Grout — I I Irrigation _..Approx. Depth I Eastern Surface al Installed-by - - Repair Work Done Q Type of Pump H.P. State-Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50'1 r - TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRYADDITION l I DESTRUCTIONX avlo s -lable ptt� system ithin m 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 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 11 Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line € DISPOSAL PONDS ❑ 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 tali for alLrenwired inspections. Complete drawing on reverse side. —� Signed X Title: Date: F DEPARTMENT USE ONLY f Application Accepted by __ Date Area I Pit or Grout Inspection by to Final Inspection by Date II Additions! Comments: l7.?6 U - / ❑ Stk 466.6781 ❑ Lodi 3694621 ❑ 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 FEF AMOUNT ;E1 A OUNT REMITTED CK ti RECEIVED BY DATE PERMIT•NO. )NFO EH 13-24IREV.rin5) I EN 14"2(i c�