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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED {Complete in Triplicate} application is in sewage or Na. 1862 for weld pump and the Rules and Regulations of the San Joaquin Application is hereby made noJoaquin San County Ordinance a Health District for ser a9ermit to construct and/or install the work herein described.This made in compliance with San Local Health District. . Lot SizePM city Job Address ' � Phone .r 0 Address Owner's am - t / �oB License N� m1 Phone F Address Contractor DESTRUCTION A NEW WELL ❑ WELL LACEMENT ❑ TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ OTHE ❑ PUMP INSTALLATION rr OV PROP. LINE ~� .S SEWER LINES �---- DISPOSAL FLD. DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS FOUNDATION AGRICULTURE WELL CONSTRUCTION SPECIFICATIONS INTENDED USE TYPE OF WELL PROBLEM AREA ipia. of Well Casing Dia. of Well Excavation {- L] Industrial ❑ Open Bottom ❑ Manteca Specifications w ❑ Tracy Type of Casing \ ❑ Domestic/Private ❑ Gravel Pack Type of Grout �\ H Other Ll Delta Depth of Grout Seal I"] Public Surface Seal Installed by \ I I Irrigation / Approx.F Depth l I Eastern State Work no j Type of Pum H P DQE Ik Repair Work Done ❑� Yp p tr Material trop 5[1'1 Well Destruction J� Well Diameter Seating Depth �� Filler Material (Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION l I DESTRUCTION 4 I availableNo �wthin 200 feetc system �t�ed if public sewer is installation will serve: Residence Commercial Other - Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Capacity- No. Compartments SEPTIC TANK ❑ TypeIMfg Method of Disposal PKG. TREATMENT PLT. ❑ Foundation Property Line Distance to nearest: Wel{_�— f I i Nx Total length/size _ LEACHING LINE ❑ No. & Length of lines Property Line FILTER BED ❑ Distance tonearest: Well Foundation I SEEPAGE PITS [A Depth i Size Number SUMPS LlDistance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ k 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 I l rules and regulations of the San Joaquin Local Health D�trict. I certify that in the performance of the work for which this permit issued, I she not Home owner or licensed agent's signature certifies the following: employ any person in such manner as.to become subject to workman's compensation Yaws 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." I The applicant must call for all required�inspections. Corn plete drawing on reverse side. Title: Date: Signed X .��' F F /� c,�E f.R ?�`�►-/�/.rE /0�3�� FUR PARTMENT USf ONLY 1. 1 Date Area ApplicationAccepted by I Date� Final Inspection by Dat6� Pit or Grout Inspection by i Additional Comments: C1 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTEQ CK RECEIVEQ BY DATE PERMIT"NQ. r �``aa 2C� �k-13 +.EH13-24rREV.5/H5) ,] VW ✓✓ �! EH 14-28 - .... - ..