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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELiON AVE., STOCKTON, CA Telephone (209) 466-6781 1, PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Joaquin Local Health District for a pe rmit to construct and/or install the work herein described.This application is Application is hereby made to the San un1862 for Nelllpump and the Rules and Reputations of the San Joaquin made in compliance with San Joaquin County Ordinance No,549 for sewage or No. Local Health District. y CityK Lot Size_ PM Job Address _—J 4 p Phone Address �8 idtriY \.`� h..• r.. ... .Owner's Name . Contractor W � Address ��,� �i/1 /*�d�'r License IS Z —Phone OF WELLlPUMP: _ NEW WELL 11 WELL REPLACEMENT ElDESTRUCTION ❑ SYSTEM REPAIR ❑ OTHER O j PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION — Diaof Well Casing O Industrial Open Bottom O Manteca Dia- of.Weil Excavation _ — Specifications Type of Casing - Q O Domestic/Private ❑Gravel Pack ❑Tracy Type of Grout I delta Depth of Grout Seal fl Public f1 Other I I Irrgation _Approx.'Depth l 1 fastarn Surface Seal Installed by ' H.P. - State Work Done Repair Work Done ❑ Type of Pump Sealing Material Itop 50") Well Destruction Cl Well Oiameter FY Depth T Filler Material (Below 50'1 { TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I.i+ DESTRUCTION t 1 availabllerw thin systex200 feet.) installation ted rf public sewer is pl Installation will serve: Residence Commercial,_ Other . Number of living units: Number of bedrooms �- Water table depth -fin { Character of soil to a depth of 3 feettll +Z Capacity t�� — No. Compartments _ SEPTIC TANK 0 'Type/Mfg Method of Disposal PKG. TREATMENT PLT'EJ D' Property Line AVOW'. Foundation Distance nearest: Well _..- Y- — i y0 __ Total length/size � 1 LEACHING LINE s'O ;No. &Length of tines D _ Property Line t D b Foundation 1 FILTER BED �. O Distance to nearest: Well�� • �. it Depth SEEPAGE PITS Property Line `, __ _Sire• t : .Number. 4' Distance to neatest: Well if'Op� Foundation SUMPS I I DISPOSAL PONDS ❑. I hereby certify that I have prepared thin application and that ttie work will.be done in accordance with San Joaquin county ordinances,state taws,and rules and regulations of.the San Joaquih Local Health District., Home owner or licensed agent's signatdre certifies the following:"1 certify that in the performance of the work fa`t is hiring permit o issued, I shah not employ any person in such manner as toibeconte subject to workman s compensation laws of'California;",Cantractbr's hiring or sub contracting signature certifiei the following: I certify that in ttra performance-&the work far which this permit is issued,t shall employ persorls•subject to workman's cornpensa- tion laws of California." AA } The applicant mus all for ail required inspectionsl Complete drawing on reverse side. F� r t J Date: • {? I•�Title: ' Signed X_ ° FOR DEPARTMENT USE ONLY r '16.124 _ Date Area . . Application Accepted by ,._.. _- e « �" -Final Inspection y Date Pit or Grout Inspection by Date_ a �- t --Additional Comments: dpxJr� .n a( O Stk 466-6781; �t O Lodi 369-$621 ❑ Manteca'823-7104 ❑ Tracy 835 Applicant• HealthParmit/Services 1601 E. Hazelton Ave., P.O: $ox Return all copies to_Environmental2009, Stk.,CA 95201 I _ r PEE AMOUNT DUE AMOUNTRECEIVED BY DATE PERMW NO. REMrtTED , I INFO •EH 1321(REV. EH 1426