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i� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I� 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I OL V,! ERMIT EXPIRES 1 YEAR FROM DATE ISSUED e Q • �� (Complete in Triplicate) /or install the work herein describe . This tr de intioom liance with San Joaqu nmade to the SanCounty Ordinance Joaquin lHealth District for a No.549 for sewage or It to No. 1862 forcwell/dpump and the Rul s and Regulations of the Sangcation is Joaquin made P Local Health District. ,1 � City Jr4 N-1107 Size PM Job Address r� �jlD �� ` ✓'"`� Phone Owner's Name Address IaI i' Address `r License No. Phone Contractor TYPE OF WELL/PUMP: NEW WELL LJWELL REPLACEMENT 01-1, NOESTRUCTION LI PUMP INSTALLATION ❑ SYSTEM REPAIR. OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 'PROP. LINE F FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ii INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing k ❑ teca Dia" of Well Excavation Industrial ❑ Open Bottom ❑ Man — f[ FT e of Casing Specifications Domestic Private- ❑ Gravel Pack ❑ Tracy YP g Other L] Delta Depth of Grout Seal Type of Grout f'l Public ` k I 1 Irrigation ,.Approx. Depth 4 1 Eastern Surf a Seal Installed by' ` Repair Work Done A Type of Pump H-P• State Work Done Well Destruction L] Well Diameter Sealing Material (top 501 f Depth Filler Material [Below 501 C3 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I (No septicailable csystem per hilted if public sewer is e Installation will serve: Residence_ Commercial— Other ;l Number of living units: Number of bedrooms Character of soil to a depth oWater table.depth f 3 feet: �i r Capacity No. Compartments j IISEPTIC TANK ❑ Type/Mfg k ;PKG. TREATMENT PLT. 11 Distance of Disposal Distance to nearest: Well Foundation Property Line Ii - f LEACHING LINE LI No. & Length of lines Total lengthlsize . I�FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well ,Foundation Property Line DISPOSAL PONDS ❑ f[ f 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 r �.rules and regulations of the San Joaquin Local Health Di§trict. r i 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 ff employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature I 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' comp nsa ;I tion laws of mia." i` The icant m t call for all re r inspe ons. Co ate drawing on rse side. l Title: Date: I Signed FOR DEPARTMENT USE ONLY I Area j Application Accepted by Date J Z� I Pit or Grout Inspection by Date Final Inspection by Date/ L Additional Comments: ❑ Stk 466-6781 ,0 Lodi 369-3621 . ❑ Manteca -823-7104 �O Tracy •835-6385 Y ,l Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 n� r� II IN O AMOU^N�T DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT Nt7. i.EH 13-24(REV.1/H 5S EH 1446