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FS- APPLICATION FOR PERMIT 4 I SAN .lOAQUIN LOCAL HEALTH DISTRICT 1- 1601 E. HAZE i ON AVE., STOCKTON, CA 11,—_71JC7 � �� . f Telephone 12091 466-8781 � PERMIT EXPIRES 4 YEAR FROM DATE ISSUED I�. (Complete in Triplicate) t and/or in all the work cation is madle n I compliance with Sanade toJoaqu nthe SanCounnty OrdinaJoauin nce No. 549 for sewage or ealth District'for a permit No. 1862 forcwell/pump and the Rules and herein Regulations of This he Regulations Joaquin Local Health District. Job Address y/C� Qr � �l City_C( Lot Size PM Phone. Owner's Name Address _ Contractor JCP/� Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT d DESTRUCTION D PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCEREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNDATION AGRICULTURE WELL OTHER WEL PITS/SUMPS �`"" INTENDED USE TYPE OF PROBLEM AREA CONST SPECIFICATIONS ❑ Industrial ❑ Open Bottom Eli Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy of Casing Specifications f ,...-..,,a,.r� ..�,.,..�-....w. �.....TYPe of Grout ❑ Public Cl Oth FI Delta Depth of Gr al I I Irrigation —.Approx. Depth l I Eastern Surface Seal Installed by Repair Work D ❑ Type of Pump H.P. State Work o ''" Well Des ruction ❑ Well Diameter S ling Materia- I Ito 0' 1� Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is t available within 200 feet.) Installation will serve: Residence_)� Commercial — Other Number of living units: _zE_ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth Capacity No{Compartments SEPTIC TANK Type/Mfg 3 �. i PKG. PLT. ❑ Method of Disposal-TREATMENT f r Distance to nearest: Well Foundation Property Line k LEACHING LINE ❑ No. & Length of lines Total length/size FILTER HED ❑ Distance to nearest: Well Founda n Property Line SEEPAGE PITS I I Depth Size Number i SUMPS L] Distance to nearest: Wel } Foundation Property Line DISPOSAL PONDS ❑ t 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. j ollowing: "I certify that in the performance of the work for which this permit is issued, I s Home owner or licensed agent's signature certifies the f halt not !I 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." y The :Ppllcanrt=f4uir ins ctions. Complete drawing on reverse side.Title: Date: Signd X FOR D TMENT USE ONLY I Application Accepted by Date ^� Area d I Pit or Grout Inspection by ' Date Final Inspection by Date � Additional Comments: ' 2 � 7 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 Eezelton Ave., P.O. Box 2009, Stk., CASA 1 FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. CASTT INFO n�7 I1ly + ;REV.iiN51 �Siof� AV V'(� Q V (�C, EH 13-24 �� 10 EH 1426 v ��