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1 APPLICATION FOR PERMIT 7 SAN JOAQUIN LOCAL HEALTH DISTRICT Y 1601 E. HAZEL T ON AVE., STOCKTON, CA O Telephone (.209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATl1 ISSUED "Y (Complete in Triplicate) .This cation is Application is hereb wrrrh SanoJoa u the n County Ordinance No.549 for sewage or n Joaquin Local Health District for a permit No 1862 for cwe Ildpump install nd the Rules and herein Regulations of he San'Joaquin made in compliance q Local Health District, � Job Address City Lot Size !i �-c PM Owner's Name . ds�► -- - Address- �'`y'4' C Phone Contractor L 11 &C Address 6V+'TLicense No. Z y Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i OTHER ❑ ! PUMP INSTALLATION ❑ SYSTEM REP ❑ 3 DISPOSAL FLD.DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PROP. LINE 1 FOUNDATION AGRICULTUR LL OTHER WELL PITS/SUMPS .l INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial L7 Open Bottom ❑ Ma a Dia. of Well Excavation Type of Casio Specifications ❑ Domestic I Private ❑ Gravel Pack racy yp g Type of Grout M Public F1 Other ❑ Delta Depth of Grout Seal ' I I Irrigation —.Ap Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ T of Pump H P State Work Done Well Destruction Well Diameter Sealing Material Itop 501 Depth Filler Material 113eiow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION l 1 DESTRUCTION I I availablelwthin 20system 0 feet1.)tted if public sewer is Installation will serve: Residence Z Commercial_ Other j Number of living units: Number of bedrooms r� I N Water table depth Character of soil to a depth of 3 feet: t ,f ah iL.rel Capacity r RA7 •-,— No. Compartments SEPTIC TANK Cir Type/Mfg s�--^-- PKG. TREATMENT PLT.❑ f r Method of Disposal Distance to nearest: Well 1602 Foundation_ 0 .Property.Line ` _ LEACHING LINE No. & Length of lines �' Total length/size y Foundation I 0 ` Property line ^S .,.FILTER BED ❑ .Distance to nearest: - Well1130 � �r SEEPAGE PITS l 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 p rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the Tollowing: "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-r� tion jaws of California." The applicant must call for all required inspections. Complete drawing on-reverse side. p Data. Signed X Title: x' FOR DEPARTMENT USE ONLY / Date Area Application Accepted byl �� ,,Q Pit or Grout Inspection by Final Inspection by Date f� Additional Comments: C3 Stk 466-6781 E) 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 OUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMI7'NO. INFO +.04 13-24 IFIEV.r i n ei EH t4-29 Ls