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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T Ofd AVE., STOCKTON, CA r Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) /A —11111 � made nt1compliance with San Joaquin the nCounty Ordinauin lHealth District for a nce No. 549 for sewage or permitto 1862 forcwell/pump and the Runes and/or'install the work 'R Regulations of tlhe Sanapplication Joaquin Local Health District. j� fih �� City I D/ PM Job Address ,. 1 � `T 5 `S �a�J�� Lot Size — ��(1� Address 5+� '� ' Phone O Owner's Name ��Q SL) SO F'� ` Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REP IR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SE ER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRI ULTURE WEL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR CON RUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r'1 Public ❑ Other C7 Delta epth of Grout Seal Type of Grout — I I ifrigation --Approx. Depth l I Ea st4r S ace Seal Installed by Repair Work Done ❑ Type of Pump ✓ H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material It p 50'I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION ! I DESTRUCTION aNailabpticle system ithin m rented if public sewer is (� Installation will serve: Residence Commercial_ Other Number of living units: _1_ Num bero f bedrooms .-� Character of soil to a depth of 3 feet. table depth SEPTIC TANK K Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. CI f Method of Disposal Per Distance to nearest: Well +p Foundation YLO_..— Property Line LEACHING LINE )C No. 8 Length of lines Total length/size " FILTER BED ❑ Distance to nearest: Well. 1.t�_ Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ill be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application and that the work w 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 inspections. Complete drawing on reverse side. Signed Title: Date: FDR DEPARTMENT USE ONLY i Application Accepted by Date Area 4A_ Pit or Grout Inspection by Date FinaQ pee ion DatwIt Additional Comments: re ❑ 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 95201 FEE AMOUNT DUE AMOUNT REMITTED AS RECEIVED BY DATE PERMIT NO. INFO a EH 13-24 IREV.'/851 V v ` - nt(,) t U ~�� EH 14-26