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r � APPLICATION FOR PERMIT Yy SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED i (Complete in Triplicate) I /or install the rk .This cation is Application is hence with Sano)Joaquin County Ordinance lNo. 549 for sewage or istrict for a permit 1662 for well/dpump and the Rus and IR Regulations of he San f Joaquin made in compliance F^ Local Health District. Z f 7� City Lot Size PM Job Address Phone I Owners Name _ T ,/ ? Address License Phone Contractor L _ AddressId No '^ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Ria. of Well Excavation Specifics"tions Q Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing I l Public fl Other ❑ Delta 'Depth of Grout Seal Type of Grout " I I Irrigation —Approx. Depth t i Eastern Surface Seal installed by Repair Work Done 171 Type of Pump H.P. State Work Done ' Welt Destruction ❑ Well Diameter Sealing Material (top 501 . Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l 1 DESTRUCTION I I alvailableo selw thin 200 feet.)system if public sewer is r� Installation will serve: Residence Commercial, Other Number of living units: - Number of bedrooms e— Water table depth Character of soil to a depth of 3 feet: . 4 SEPTIC TXCNK ❑ Type/Mfg Capacity— No. Compartments F Method of Disposal PKG. TREATMENT PLT. ❑ F7 Distance to nearest: Well6 Foundation property LineQ l F': LEACHING LINE l No. & Length of tines Total length/size a � 1 FILTER BED ❑ Distance to nearest: Well va d` Foundation � Property Line ,r� �rNumber SEEPAGE PITS [ I Depth Size _ I --- SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t he work will be done in accordance with San Joaquin county ordinances, state laws, and 1 hereby certify that I have prepared this application and that t rules and regulations of the San Joaquin Local Health Di1trict- 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." Contractors 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' quire inspactio s. Complete drawing on reverse side. ��yy Signed X r / Title: Date: �Z--�G iI - F ARTMENT USE ONLY I Application Accepted by Rate r Area 7 1 Date Final Inspection by Date/ Pit or Grout Inspection by Additional Comments: ❑ ❑ Stk 466-6781 Lodi 369-3621 CI 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 FEE AMOUNT DUE AMOUNT REMITTED K H RECEIVED 8Y DATE PERMIT'NO. INFO Fil + EH 13-24 4AFv.t/x 5) EH 14-26