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APPLICATION FOR PERMIT C75 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) Appliat to /or install the work n described. This cation is madec n compliance wis hetebyith San Joaqu nade to the SanCouJoamy Ordinauin nHealth District for a ce No. 549 for sewage or'No. 1862 forcwellldpump and the Rules and'R Regulations of the San Joaquin Id[} Local Health District.. `\05— 2 ti ^ ` City .S Lot Size PM Job Address G ';Its � 3 I �J •• _ �/'lhnl &iii y/ v Address t Phone Owner's Name - 9 Contractor � � < Address /� 36 C53' License No.� ��` ZPhone S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Cl DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (3 Industrial [I Open Bottom E3 Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1Public F1Other F1Delta Depth of Grout Seal Type of Grout 1 1 Irrigation _..Appwx. 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 (top 501 Depth Filler Material (Below 501 -- TYPE OF SEPTIC WORK: NEW INSTALLATION l'I REPAIRIADDITION t 1 DESTRU I I fNo septic system permitted if public sewer is available within 200 feet.i 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 Capacity No. Compartments 2 PKG. TREATMENT PLT, 11 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 l I Depth Size Number SUMPS 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, and rules and regulations of the San Joaquin Local Health Di§trict. 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 compensa- tion tawsof lifornia." The app t us for all re it inspect* s. Complete drawing on reverse side. Signa w Title: Date: � y� FOR DEPARTMENT USE ONLY Application Accepted by wvim-+ Date Area Pit or Grout Inspection by Date 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, Silk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE J. PERMIT NO. INFO �^ + Er 13-24(REV.t i H 5) �1� T EH 1428 �•7