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...................... —r - APPLICATION FOR PERMIT � r d SAN JOAQUIN LOCAL HEALTH DISTRICT y� 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) cribed,This application is construct /or install the work Application is fiereby made to the Sart CouQty O dinanHe No.549 for sewage or permit to 1862 for wellldherein pump and the Rules andRegulations of the San Joaquin made in compliance with S q Local Health District. /t �Llzvid City of Size PM Job Address f £�f Phone X Owner's Name i Address r Contractor Address License No. phone __—.— NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF WELLIPUMP: SYSTEM REPAIR ❑ OTHER ❑ PUMP INSTALLATION ❑ SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL— PROBLEM FOUNDATION AGRICULTURE WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial~— ❑ Open Bottom 0 Manteca Dia. of Well Excavation Specifications ❑ DomestiO Private ❑ Gravel Pack ❑ Tracy Type of Casing F1 Other (71 Delta Depth of Grout Seal Type of Grout I i Public ..Approx. Depth l 1 Eastern Surface Seal Installed by I I Irrigation — State Work Done _ Repair Work Done ❑ Type of Pump H.P. Well Destruction ❑ Weil Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION (No ailableseptic w thin 200 feetitted if public sewer is Installation wilt serve: Residence Commercial, Other the � �4 7 "� Number of living units: Number of bedrooms---?--- $ Water table depth Character of soil to a depth of 3 feet: r 1 Capacity .4 n V C' S.t No. Compartments SEPTIC TANK Type/Mfg =—�-a-- 0- �� Method of Disposal PKG. TREATMENT PLT. r �— Property Line Distance to nearest: Well) Foundation s - Total length/size LEACHING LINE ❑ No. & Length o Property Line ❑ Distance to nearest: Well Foundation FILTER BED t � Number SEEPAGE PITS 1 1 Depth Size ,� ' BLIMPS Ll Distance to nearest. Well Foundation Property Line DISPOSAL PONDS ❑ 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, an 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 signature shallnot employ any person in such manner as to become subject to workman's compensation laws of California ."Contracgon$tsub'ect to workmanring or �scompensa certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ p 1 tion laws of California." ctions. Complete drawing on reverse side. The applica ust tail r all requir in �� � Date: — Title: \/ Signed FOR DEPARTMENT USE ONLY �^ Date v � 4-7 Area Application Accepted by Pit or Grout Inspecti y Data Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 CASH RECEIVED BY DATE PERMIT'NO. INFO ( Q� + EN 13.24(REV,i i ra 5l �O F�0 0 �LDd�] Uj(/ f 0" 00 T'� EH 14-2e