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s � 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) . This cation is /of inall the work n de Application is hereby made othe n County Ordinance No.549 for sewage or tNo. 1662 for well/t to construct dpump and the Runes and tR gulations of the 5anl Joaquin made in compliance with SanJoaquin Local Health District. City S ,r�' ot Size PM Job Address Phone Owner's Name Q —rte' Address Contractor 4 ' Address f� Z- rr License No._�.�Phone�! TYPE.OF WELL/PUMP: NEW WELL El REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION IJ DISPOSAL REPAIR [I 'OTHER ❑ i SEWER LINES DISPOSAL FL'D. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS ' FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing �' ' 54odustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications ❑ C6mestic/Private Type o 'r L-1 Gravel Pack El Tracy ypf Casing l l Type of Grout r f Other C! Delta Depth of Grout Seal W FI Public Approx. Depth l I Eastern Surface Seal Installed by 1 1 Irrigation — Slate Work Done _ Repair Work Done ❑. �' Type of Pump H P o Sealing Material (top 50'1 I Well Destruction ❑ Well Diameter ' Depth YFiller Material (Below 50') .l TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR IADDITION l I AUESTRUCTION i availabletw thine200 feeit�ed if public sewer is Installation will serve: Residence Commercial .Other 1 x- r �a _ �--�- ,.ter- =-= :.... _ Number of living units: Number of bedrooms - P + r %_ - Water table depth Capacity Character of soil to a depth of 3 feet: No, Compartments � Disposal SEPTIC TANK . ' Type/Mfg � �r / � Methotf of Dim sal t PKG. TREATMENT PLT. ❑ /s Line Distance to nearest: Wel! »Q Foundation Property Y & 1 No. & Length of lines �L6�s Total length size LEACHING LINE Property Line ( FILTER BED Ll Distance to nearest: Well Foundation p Y �/2 i/ / Number SEEPAGE PITS AM Depth�M� Size SUMPS Ll Distance to nearest: Well �fl Foundation-LAV `Property Line —{ I DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordarice 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 in such manner as to become subject to workman's compensation laws of California-" Contractor's hiring or sub-contracting signature certifies the following: certify that in the performance of the work for which this permit is issued, Ishall employ persons subject to workman's compensa , r tion laws of California." F The applicant must cal all re 'e pact' omplete drawing on reverse side. /�� Signed X + Title: O""t""'�t'�ate: 1 - F ARTMENT USE ONLY 2�''1 Date Area C/ Application Accepted by r Date i Date Final Inspection by _ Pit or Grout Inspection by r Additional Comments: ❑ Additional 4l Com 1 ❑ Lodi .369-3621 ❑ Manteca 823-7104 ❑ Tracy 5-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK RECEIVED BY DATE FEE PERMIT NO- AMOUNT DUE AMOUNT REMITTED CASH INFO, r EH 13-24 IREV.t/n 5t -�� (� • �� i` fH 14-26