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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) oaquin Local Health District for a permit to construct and/or install the work herein described. This application is Application is hereby made to the San J o.549 for sewage 6r No. 1862 for wn ewpump and the Rules and Regulations of the San Joaqui made in compliance with San Joaquin County Ordinance N Local Health District. 4545 N. Wilson Wa City St0Ckt0rl Lot Size PM. Job Address 180 Grand Ave. , #900 Don A. Son Address Oa�d-�Sa g4- Phone Owner's Name 4500 E. -Fremont .Contractor NOACK SAN JOAQUIN PUMRddress Stockton Ca License No. 504513 Phone - 8817 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONOTHER ❑ PUMP INSTALLATION H SYSTEM REPAIR El 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 Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Type of Casing-----!— Domestic asing Specifications DomesticIPrivate ❑ Gravel Pack ❑ Tracy Type of Grout - M Public C I Other ❑ Delta Depth of Grout Seal 9 I Irrigation —Approx. Depth 4 I Eastern Surface Seal Installed by Repair Work Done Type of PUMP Ig�.P• 3 HP State Work Done —Pl..IMP REPI ACE { Well Destruction ❑ Well Diameter Sealing Material Itop 601 v` Depth Filler Material I8elow 50'1 j TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION I I DESTRUCTION I I a ailabptic system m rented if public sewer is V� Installation will serve: Residence_ Commercial_ Other 'w Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: W Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 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 I 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 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 insuchmanner as to become subject to workman's compensation laws of California." Contractor's o t ub-contraGtworkman's signatur certifies the following: "1 certify that in the performance of the work for which this permit is issued, i shall employ p 1 compensa- tion laws of California." The app ust call for all required i ctian Complete drawin ravee sid /� � Signed !� Title Date: FOR DEPARTMENT USE ONLY Application Accepted by ` r �r---�` Date Area Final Inspection by Date 16 Pit or Grout Inspection by Date - `2 Additional Comments: Ll 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 CA 5H RECEIVED BY DATE PERMIT"NO. f INFO t.EH 13-24 IREV.1/s 5) ER 14-26