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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) ibe . This location is 4 /or install the Applicatn desct ion is hereby made to the San Joaquin fd nanHe No.549 for sewage o INo. 1862 for welilt to construct dpump and the Rules and 1Regulations of the San Joaquin made in compliance with San Joaquin County Local Health District. tot Size PM City Job Address _ dq Phone `J j Q � Address Owner's Name � � �Jr*0 { �+i toN f�•f�� y7v41!8 —Phone 2�'f E �M r-„ �L-icense Ho'. Contractor RC�►C C Address ❑ s i DESTRUCTION ❑ NEW WELL ❑ WELL REPLACEMENT TYPE OF WELLIPUMP: SYSTEM REPAIR ❑ _ OTHER ❑ c PUMP INSTALLATION ❑ _�_ piSPOSAL FLO. PROP. LINE DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES K PITS/SUMPS t FOUNDATION t AGRICULTI�RE W L OTHER WELL INTENDED USE TYPE OF WELL `` PR08LEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial --• -"❑ Dia. of Well Excavation Open Bottom ❑ Manteca Specifications ❑ Tracy Type of Casing ❑ Domestic/Private ❑ Gravel Pack Depth of Grout Seal Type of Grout -- Cl Other t CI Delta _ I`1 Public j 4 ¢ Surf Seat installed by k I I Irrigation,. �_AQprox. Depth I 1 Eastern rte, .� H P 't="i�f State Work Done_ j Repair Work Done ❑ Type of Pump �— s i Well Destruction ❑ Well Diameter Sealing Material (top 501 i f r. Depth Filler Material lBelow 50'1 wavailable within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION { REPAIR/ADDITION. l I DESTRUCTION l I (No septic system permitted if public sewer is i Installation will serve: Residence Commercial_ Other Number of living units: —�.— Number off b rooms Water table depth Character of soil to a depth of 3 feel 0h � No- Compartments Capacity SEPTIC TANK ❑ Type/Mfg Method of Disposal ( PKC. TREATMENT PLT.�� S 1t` J Property Line Foundation t-^— w....,. Imo_ '• Foundation `"Distance, -nearest: Wellr� ' ❑ No. & Length of lines �Vt Total length/size LEACHINGLINE Foundation Property Line FILTER BED ❑ Distancelio nearest: Well fe r Number SEEPAGE PITS l I Depth Size I #Foundation Property Line SUMPS Ll -Distance to nearest: Well DISPOSAL,PONDS ❑ Y 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 agent's San Joaquin Local Health Di$trict.g y rfor ahc6 of the work for which this permit is issued, I shall not I Home owner or'licansed si nature certifies the followin I certif that in the pe signature employ any person in such manner as ko become subject to workman's compensation I s•of California ploy 6rsonsrsubj cit t workman!scompensa- certifies the following:"I certify that in the performance of the work for which this permit is issued, I�sa employ p f. tion laws of California." �+ a I The applicant must call for all required inspec ns. Complete drawing on reverseesLiside. /2- q_�O Titlei:F �.a� Date: '7 I Signed X t S.: OR DEPARTMENT USE ONLY a I r Date — Area Application Accepted by . , Date l Final Inspection by Date Pit or Grout Inspection by ,� ��` -.- Additional Comments: a ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 923 7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 85201 —A OUTFIT REA71VTTED— CASH AS-- � RECEIVED BY DATE PERMIT ND. - —FEE—p;f�pl1NT-Pt)E CAFI INFO �� ..EH 13-24 IREV.I/H 51 r EH 14-26 4