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y,..� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 1209) 466-6781. p P, J PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) " 3Q� t and/or all the wqrk q described. Applicartioon�s lhae� a w�'h Sano the Joaquin County Ordinance No. 549 for sewa permit No. 1862 forcwe]i pump and the`hul6 ane fFie ulatioris of This application San Joaquin 9 � ,� made P g Local Health District. r Cit Lot Size PM Job Address � Address Phone Owner's Name ' ��License No Contracto - Address l� G� �— na TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR X OTHER 13 ` SEWER LINES DISPOSAL FLO. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ eca MantDia. of Well Excavation Type of Casing Specifications ['Domestic/Private ❑ Grave! Pack LI Tracy Type of Grout � f`l Public 171 Other F1 Delta Depth of Grout Seal . I I Irrigation _Approx. Depth I l Eastern Surface Seal Installed by State Work Done Repair Work Done �Q Type of Pump� H P _ Well Destruction [-IWellDiameter Sealing Material (top 50'1 f Depth Filler Material IBelow 501 — �✓ TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION.Li DESTRUCTION I I (No septic system m permitted if public sewer is available installation will serve: Residence— Commercial Other ��n/� V] (1 Number of-living units: Number of bedrooms i Character of sail to a depth of 3 feel: '` Water table depth -_ I Capacity No. Compartments k SEPTIC TANK ❑ Type/Mfg r. i E Method of Disposal PKG, TREATMENT PLT. ❑' Distance to nearest: Well Foundation Property Line C Total length/size LEACHING LINE ❑`No. -Length of-lines. I FILTER BED ❑ Distance to nearest: Well Foundation Property Line ,-'`�-,'tSEEPAGE PITS l I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line A DISPOSAL PONDS ❑ I hereby certify that I have prepared Ihis application and that the work wili.be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health D3trict. 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 m It all for required inspections. Compieti3 drawing on reverse side. Signe Title. Date: FOR DEPA TM ENT USE ONLY µ Q Date Areay Application Accepted by /� w Date y Pit or Grout Inspection by Date Final Inspection by 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, Stk., CA 9524] FEE CK RECEIVED BY DATE PERMIT'NO. INFO AMOUNT DUE AMOUNT REMITTED CASH +.EH 1324(REV.r I e 5) EH 14-26