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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) n /or install the work herein describ , This g is Application is hereby made to the San Joaquin Local Health District for apermit to construct on tructor No. 1862for a Ildpump and the Rules and Regulations of he Sanl cation Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage Local Health District. 453City of Size PM Job Address [M-6 Phone Owner's Name�P•� �P fe�'t r� Address j i2(�T[ti l e License Na. Phone p1J r Contractor's Name .�,_� � TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT ❑ . DESTRUCTION ❑ 4 ` PUMP INSTALLATION. ❑ SYSTEM REPAIR ❑ OTHER ❑ I. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Y DISPOSAL FLD. PROP. LINE �-- FOUNDATION, AGRICULTURE WELL OTHER WELL PITS/SUMPS O A CONSTRUCTION SPECIFICATIONS INTENDED USE TYPE OF-,WELL PROBLEM AREA i Dia. of Well Casing [71 Industrial El Open Bottom E3 Manteca Dia. of Well Excavation .�_ ._ ❑ Domestic/Private ❑ Gravek'Pack ❑ Type of GasinTracy g- Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface_Seal Installed by Repair Work Done r❑' Type of Pump H.P. State Work Done Well Destruction 40 Well Diameter Sealing Material (top 501 `• V fi n Depth Filler Material (Below 50'1 ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION' DESTRUCTION ❑ (No septic system permitted if public sewer is W available within 200 feet.) 4 Installation will server Residence_X1 Commercial_ Other _ Number of living units: Number of bedrooms r� 1 / Water table depth Character of soil t6-a depth of 3 feet' — � SEPTIC TANK El' Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT ❑ Method of Disposal Distance to nearest: Well,- Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distanceto nearest: Well Foundation Property Line '� Number SEEPAGE PITS Depth Size aI 1 .. SUMPS ❑ Distance tFoundation Property Line 4o nearest: WeU 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 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: "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 Cal'rforriia:"_�_ _ The applicant must call for all re o . Complete drawingjreverg;Ide Signed Title: Date: f FOR DEPAR /EN,T, t!SONLY y G+ Date. z a Area Application Accepted by, 1� Pit or Grout Inspection by Date Final-Inspection by Date 1� i /Ya Additional Comments: ❑ Stk 46r6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy. �836 6385 Applicant- Return all copies to: Environmental Health Permit/Services 1.601 E.'Hazelton Ave., P.O. Box 2009, k., CA 9/V9 /�/ F7 J t FEE CK# '� - RECEIVED BY DATE PERMIT''NO. _ INFO AMOUNT DUE AMOUNT REMITTED CASH y + EH 13.24(REV.10!83) EH 14-M -