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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. Hill ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) application.This ;s /or install the work I Application is hereby made to the San Joaquin County 0 d nalnce No.HealthD549 for sewage o(No. 1862 for wail/t to construct dpump and the Rules and IR gulatibns of he San Joaquin made m compliance w 1 Local Health District. Q � ��4 d� ✓�C( C Q (I�� City /7c U " '4'r «^Lot Size — PM k 1 Job Address �. t Z 3 Y — D 1 / -f 11 7 7 .I�„1 e r -e Phone Owner's Name ce: e " Address `�� 1 f c Phone *-Ll /'ClC i' /4:0 ll License No. i Contractor's Name WELL! ❑ DESTRUCTION ❑ TYPE OF WELL/PUMP: NEW1. WELL OTHER ❑ PUMP INSTALLATION)l SYSTEM REPAIR ❑ r SEWER LINES DISPOSAL FLD. PROP. LUNE DISTANCE TO NEAREST: SEPTIC TANK _� OTHER WELL PITS/SUMPS FOUNDATION AGRICULTURE WELL r f� INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing ❑ industrial ❑ Open Bottom Manteca Dia. of Well Excavation - E I ' ❑ Tracy Type of Casing Specifications [�2 l Domestic/Private g Gravel Pack p Type of Grout` ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ❑ irrigation /7._�lpprox. Depth O'Eastern /Surface Seal Installed by H P State Work Done I Repair Work Done ElType of Pump Sealing Material (top 50'1 Well Destruction ❑ Well Diameter ! Depth I Filler Material [Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ 1EPAIRIADl"ll"ll"ll ll" DIT"llION ❑ DESTRUCTION ❑ availableseptic within 200 feet.)ited if public sewer is serve: Residence Commercial_ Other installation will t Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal ( PKG. TREATMENT PLT. ❑ „� Property Line Distande to nearest: Well Foundation t Total length/size LEACHING LINE [:3No. & Length of lines property tine FILTER SED ED Distance to nearest: Well Foundation Number I SEEPAGE PITS [7 Depth !—Size Property Line i SUMPS LlDistance to nearest: Well Foundation 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, an t rules and regulations of the San Joaquin Local Health District. i Home nd regulations 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 ailr wired inspe tion . Complete drawing on reverse side. y 10/1Title: �r Date: [ Signed FOR DEE&RTMENT USE ONLY Date Area g� Application Accepted by _ l Fine inspection Inspection by Date 6'® Pit or Grout Inspection by Date/ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 . ❑ Tracy 835-6385 Stk., CA 55201 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, FEE fF CK# RECEIVED BY DATE PERMIT NO. INFO AMOUNT DUE AMOUNT REMITTED CASH + EH 13-24(REV.Will /D c►i rase