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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Appi t and/or install the work cation is madle in conmplliance with San Joaquin eieby ade to the nCounty OrdinaJoaquin lnce No.549 for sewage or Health District for a permit No. 1862 for cwell/pump and the Rules and hereinR gulations of he San'Joaquin Local Health District. W,-�O/ /P/"7A � City GG i Lot Size PM Job Address r ///L�i�✓rte // .T/ln'I Address ��l'' Phone Owner's Name60, 57G 2 ��Z 3 Z s/G� T ^� �rfContractor Cd�G✓< h� Address/ ^'�I ��-C��1��J{/ T License No`s 7 'ted/,/� Phone 7 37Z "C TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION U ?1W�p PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ W/ C .JDISPOSAL n /.., nOAi n. 'ff i z/..<1PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD� fj'p FOUNDATION AGRICULTURE WELL OTHER WELL* wry 'PITS/SUMPS _ INTENDED USE 0 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Zz/ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation p'r Dia, of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing— ��G Specifications M Public n Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Well Diameter " Sealing Material Itop 501 x't.J�–g Depth S/F� Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I I availaeptic hit system rented if public sewer is Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line p/ DISPOSAL PONDS ❑ (O� 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 Dstrict. Home owner or licensed agent's signature cartifies 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 compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X��/ Title:S✓ 'S Date: OR DEPARTMENT USE ONLY Application Accepted by � Date �+' Area Pit or Grout Inspection by ate Final Inspection by D Additional Comments: fn '`R III ❑ Stk 466-6781 ❑ Lodi -3621 anteca -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 PEflM1T NO. INFO . EN 13 IREV.1/x sl �v EH 147a ab