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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE' ON AVE., STOCKTON, CA Telephone {209) 46r)-.6781 r, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t (Complete in Triplicate) _._ Application is hereby made to the San Joaquin Local Health District fora _ made in compliance with San Joaquin County Ordinance No.549 for sewage permit rNo. 1862 for well/pump and he Rules and Regthe work herein ulations �a application n Local Health District. ' Joaquin Job Address City ;tY '(J Lot Size PM L/ (^: Owner's Name _f w.'lJj Cy Address 1 �f Phone ! # Contractorf'�/' ,/ r`_/ _Address (1 7 TYPE OF WELL/PUMP: License No. 2C LPhone NEW WEEWELL REPLACEMENT DESTRUCTION ❑ i PUMP INSTALLATION w DISTANCE TO NEAREST: SEPTIC TANK _ SYSTEM REPAIR O OTHF,R ❑ SEWER LINES — DISPOSAL FLD. ��1/! PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL—_ PITS/SUMPS , INTENDED USE TYPE OF WELL P OBLEM AREA CONSTRUCTION SPECIFICATIONS r/ U Industrial ❑ Open Bottom Manteca r! Dia, of Well Excavati n Dia. of Well Casin iDUvmesticlPrivate Araval Pack ❑ Trac �' Y T e of Casin Specifications f/ J� O Public El Other O Delta Type g Depth of Grout Seal O Irrigation ---Approx. Depth ❑ Eastern Type of Grout - Surface Seal Installed by R�pair Work Done ❑ Type of Pump H.P. Well Destruction ❑ Well Diameter State Work Done C Sealing Material (top 501 Depth Filler Material (Below 50') 7 F TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ AEPAIR/AD DITION ❑ DESTRUCTION ❑ INo septic System permitted if public sewer is jInstallation will serve: Residence_ Commercial Qther available within 200 feet.) Number of living units: Number of bedrooms !" Character of soil to a depth of 3 feet: SEPTIC TANK Water table depth .l Type/Mfg PKG. TREATMENT PLT. ❑ Capacity No. Compartments n 1 Method of Disposal Distance to nearest: Welt Foundation Property Line LEACHING LINE ❑ No. & Length of lines FILTER BED Total length/size } ❑ Distance to nearest: Well Foundation Property Line F SEEPAGE PITS ❑ Depth ' p Size Number SUMPS ❑ Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line 1 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 Fcompensa- tion laws of California." The mu a applicant or ail re ire ins ctions. Complete drawing on rever e. Signed Title: C ;'` Date: FOR DEPART ENT USE ONLY Fi Application Accepted by l Date Area Q l Pit[or Grout Inspect( n by Date Final Inspection by /t/ I r Data I Additional COmme t W U �• (� 1 , ❑ 5tk 4SE6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Traci/ 835-6M 1 r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. �y Stk., C 95201 F � � FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY CASH DATE PERMIT NO. FEH 1374[REV.I/asl EH 1428 S v, C� V " 1