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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 i (Complete in Triplicate) h District for a nstall the work . This cation is made in compliance ompliance wrade to the ith Sarni Joaquin nCounty ordinauin nce No.549 for sewage or ealtpermit 1862 forcwellldpumlp and the Rules and IR Regulations of he Sanl Joaquin Local Health District. City Lot Size �5L PM Job Address tPhone OE�t7 Owner's Name Address *61-96 IiCJZ/!/�rS• L 41� s � Phon Contractor dress NEW WELL ❑ WELL REPLA ESTRUCT(ON TYPE OF WELLIPUMP: ' PUMP INSTALLATION ❑ STEM REPAIR D� ' DISPOSAL FLO. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER L FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Type of Casing /=6� Specifications - Domestic/Private ❑ Gravel Pack ❑ Tracy � cr Type of Graut I ❑ Delta Depth of Grout Seal ('1 Public f❑ Other _^ - I I Irrigation /40-lApprox. Depth i I Eastern ,Surface Seal Installed by a of Pump H.P. State Work Done_ Repair Work Done ❑ Types -- Well Destruction ❑ Well Diameter _. � Sealing Material itop 50'1 Depth Filler Material IBelow 501 w TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION t 1 DESTRUCTION l 1 alvailablerw thin 20system 0 ermfeetrt}ed if public sewer is O Installation will serve: Residence Commercial_. Other I Number of living units: Number of bedrooms Water table depth 7 'Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r i PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest:. r 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 a Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be doe in accordance with San Joaquin o�nty ordinances, state laws, and 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 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 iinspections. Complete drawing on reverse side. Si ned X—F,-ice it Title: — l�+Iirt Date: �� ff T FOR DEPARTMENT USE ONLY Date Asea Application Accepted by Pit or Grout Inspection by Da te Final Inspection by Date 1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 D Manteca 823-7104 El Tracy 635-6385 � f Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 }� Z UNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. [!I }-SS7S l y r�4 ' rE+i 1321(REV.ilH5)EH 1♦-28