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. APPLICATION FOR PERMIT 1= SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) a t and/or install the work is cation is maApplicationins compliance wieteby th Sanade othe Joaq$n counan ty Ordnance Nuin Local th District for a o. 549 for sewage or permit No. 1862 forcwe I pump and the Rules and hereinR Regulations of tthe San Joaquin P Local Health District. I 3f �[ Cit Lot Size 15P,SZ /x��L�/PM Job Address �/ /l Address Phone Owner's Name _ -- Contractor "moo Address �� License No. 3� Phone_ TYPE OF WELLIPUMP: _ r NEW WELL ❑ WELL REPLACEMENT ❑ T ..�. DESTRUCTION ❑ PUMP INSTALLATION ❑ ' SYSTEM-REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial 1-1Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private = ❑ Gravel.Pack ElTracy Type of Casing Specifications (I Public ❑ Other � ❑ Delta Depth of Grout Seal Type of Grout = � I } Irrigation p Approx. Depth t I Eastern Surface Seal Installed by r Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth I Filler Material (Below 50'1 TYPE OF{SEPTIC WORK: NEW INSTALLATION r REPAIR/ADDITION l 1 DESTRUCTION t 1 (No septic-system permitted if public sewer is available:within 200 feet.i V" Installation will serve: Residence: Commercial_ Other - Number of living units: __�L Number of bedrooms 13 -__— t Water table depth Character of soil to a depth of 3 feeP1� SEPTIC TANK ❑ Type/Mfg Capacity �4 No. Compartments PKG. TREATMENT PLT. LlMethod of Disposal ^ Distance to,nearest: Well 54�_ Foundation �B Property Line $ LEACHING LINE LSI No. &.Length o1 lines Total length/size F FILTER BED ❑ Distance to nearest: Well eneg �- Foundation /4 Property Line 1 . SEEPAGE PITS tlf/Depth � Size 93 Number 3 SUMPS Ll Distance to nearest: Well � `� Foundation ^ Property Line------ DISPOSAL PONDS ❑ 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. .41 " `_A 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 man's compensation laws of California." Contractor's hiring or sub-contracting signatu employ any person in such manner as to become subject to workre, 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." x ' The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: e:batt V — ', OR DEPARTMENT USE ONLY'.,, Application Accepted by Data �rU~ Area µ ate Final Inspection'by ate -G� Pit r Grout Inspection by CP i 1 Additional Comments: _ _ ._ — ----- xOYStk 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 FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO w.y y EH td-2e + EH 13-24(REV.F/N51 I -