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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) i d Application is compliance with SanJoaqu n Counreby ade tthe San gty ordinance No. 549 for sewage or Local permit 1662 for well/pump install herein application uin and the Rul s and Regulations of the SanJoaquin made in comp Local Health District. �'r7ad Lot Size PM Job Address City t Phone Owner's Name /9�� a I Address r UL Add,,,, License Nb.,:k Phone Contractor WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF WELL/PUMP: NEW WELL i❑_, ,�v OTHER ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ LDISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FOUNDATION AGRICULTURE WELL OTHER WELL:— INTENDED INTENDED USE TYPE OF WELL _PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia- of Well Casing ❑ Industrial ❑ Open Bott6A ="❑ Manteca Dia- of Well Excavation Jype Of Specifications t _ 13 Domestic/Private ❑ Gravel Pack ';,.D Tracy..` *� , , Type of Grout----- F] rout_— -- l`1 Public n"Other F1 Delta Depth of Grout Seal I Iirrigation —.-Approx. Depth t I Eastern Surface Seal Installed by k ! - ; r State WorkeDone_ Repair,Work Done ❑ Type of Pump H.P;., � "R.. Sealing Material'(to '1 y Well Destruction ❑��1Ne11,Diameters r, V Filler Material (Below 50'l ' 3 Depth ►1 TYPE OF SEPTIC WORK: - NEW INSTALLATION ' REP l I DESTRUCTION I}available wiic thin 200 feet.) if public sewer is ti Installation will-serve:' Residence Commercial�,.Other _ Number of living units: --I— Number of bedrooms_ —_ '* !L a water table depth ry Character of soil to a depth of 3 feet: � SEPTIC TANK it ❑ Type/Mfg " Capacity 09 No. Compartments f Method of Disposal Line-. �L � PKG. TREATMENT PLT. ❑ k Distance to nearest: Well�� -�Foundation 3 Property / C .. LEACHING LINE ONO. & Length of lines Fr Total'lengthlsize ��r��"' `r 4 FILTER BED El Distance to nearest: Well L 1Toundation SL-.�= Property Line 3d t 5 'fix ------------------- SEEPAGE PITS a +,� l 1 Depth ��O.F1 -_Size f Number ° �r�7 SUMPS I`n I--Distance ko newest: Well � � Foundation s Property Line DISfDO 4LSPONO3 r t1Q rt •:,�+ 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 t 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 j certifies the following: u certify that in the performance of the work for which thiV-permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." - i t The applicant must call for requi d inspections. Complete drawing on reverse side. ' r Title: e Date: d Signed X ti ' OR DEPARTMENT USE ONLY r Date# /�1 _7 Area l� Application Accepted by Final Inspection by r Date Pit or Grout Inspection by Date : Additional Comments: Ell Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 Applicant Return all capias to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2609, Stk., CA 95201 a # FEE *�uAMOUNT Ot1E" p1vI0UNTASH RECEIVED BY `" DATE' PERMIT'NO. t. -__ .`�- REMITTEfl 'G % (NFO ` ^'" 7-.- �.j, P +.EH 1324 IRE-.1!N 57 .. O .- .,,,---«•.�-.+•....^^ -,...^ W .., r•: 11/1 / !-�.!') r 6 EH 14-29 }