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' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT -� 1601 E. HAZE,ION AVE., STOCKTON, CA Telephone (209) 466-6781 �.- •� PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) rk describe , This n is catio Application is hereby made to the San Joaquin fdinalncfe No.549 for sewage or ealth District for a permit Na 1f362#orcwr install the ell/dpuomp and the Rues and IR gulations of the San'Joaquin ,rnade.in compliance with San Joaquin County F Local Health District. ` City Lot Size QG� PM Job Address � ' G�f� V/0 Address Phone Owner's Name ^/ Address License No.�2 Phone �— Contractor NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION D TYPE OF WELL/PUMP: PUMP INSTALLATI SYSTEM REPAIR OTHER ❑ r' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES —1 DISPOSAL FLD. PROP. LINE ! ° FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS 'i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial LJ Open Bottom ❑ Manteca Ria. of Well Excavation pia. of Well Casing ❑ Domestic/Private E3 Gravel Pack El Tracy Type of Casing____?_&_ Specifications ❑ Other Cl Delta Depth of Grout Seal Type of Grout ,.�• ['1 Public � _ I 1 Irrigation --Approx.rox. De th I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. _ State Work Done Sealin Material [top 50'1 Well Destruction ❑ Well Diameter 9 _ Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 11, AEPAIRlADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is _ available within 200 feet.) Installation will serve: ,Residence— Commercial_ Other ,I I V _ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water sable depth SEPTIC TANK 0 Type/Mfg, Capacity No. Compartments - f j PKG. TREATMENT PLT. ❑ Method of Disposal Distance to'nearest: Well Foundation Property Line m tTotal length/size -_ LEACHING LINE �... ❑ No. & Length of Eines � A FILTER BED LI Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size r Number SUMPS Cl Distance to nearest: Well Foundation Property Line {a DISPOSAL PONDS ❑ ' `t certify that I have prepared this application and that the work will bedonein accordance with San Joaquin county ordinances, stag laws, and a �'l hereby ce y P P y 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 permis,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." i The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT SE ONLY Application Accepted by Date l Area Pit oGrout Inspection by ate Final Inspection by Date r11_ , Additional Comments: ❑ Stk 466-6781 ❑ L di 369-362 ❑ Men eco 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 - - FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMITNO. INFO CAS 'yF Qp .:EH 13.24(REV.1/95) '-r - Jq �r ^Y JC.!-q O 96 EH 11-26 ^