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l APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE:i ON AVE., STOCKTON, CA Telephone 12091 466-6781 ' PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application Is. hereby made to the San Joaquin Local Health District for a permit to construct'and/or install the work herein described.This application is F Application iheieb with San Joaquin County Ordinance No.549 for sewage or No. 1862 for ell/pump and the Rules and Regulations of the San Joaquin made incompliance Local Health District. PM City L� Lot Size r r Job Address Phone Address (�p -13 7 Owner's Name Phone fig/ i License No. Contractor Address WELL REPLACEMENT L) DESTRUCTION ❑ � - NEW WELL ❑ OTHER ❑ TYPE OF WELL/PU P. SYSTEM REPAIR ❑ PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE SEWER LINES J— OTHER WELL PITS/SUMPS E DISTANCE TO NEAREST: SEPTIC TANK --�- AGRICULTURE WELL FOUNDATION �� INTENDED USE TYPE BLDia. of Well Casing _ EM AREA CONSTRUCTION SPEC IFICATION5 OF WELL PRO ❑ Open Bottom '❑ Manteca Dia. of Well Excavation Specifications ❑ Industrial ❑ Tracy V Type of Casing � ❑ Domestic/Private ❑ Gravel Pack � Type of Grout -"----- '❑ Delta Depth of Grout Seal n 1 FI Public Other Surface Seal installed by I I Irrigation —Approx. Depth I ! Eastern State Work Done Type of Pump —-- H.P, Repair Work Done ❑ We Diameter Sealing Material ltop 50'1 k Well Destruction ❑ -- Filler Material [Below 50) Depth available within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION I S REPAIRIADDlTION I ! DESTRUCTION Mo septic system permitted if public sewer is Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Water table depth I Character of soil to a depth of 3 feet: Capacity____�_ No. Compartments r SEPTIC TANK E3 Type/Mfg Method of Disposal PKG. TREATMENT PLT- ❑ Foundation�_�- Property Line Distance to nearest: Well Total length/size LEACHING LINE ❑ No. & Length of lines Foundation property Line FILTER BED ❑ Distance to nearest: Well SiNumber SEFPAGE PITS 11 Depth- ze property Line SUMPS Ll Distance to nearest: Well Foundation-L--- 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 fules.and regulations of the San Joaquin Local Health Di§trict.g shall not Home owner or licensed agent's gas to some subject the following: wing: - 'srtcompensat on lify that in the aws California." Contractor's work for rhui gr or sub-cont act ngt is issued, Isignaturre employ any person in such mapersons subject to workman's compensa- t certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ tion laws of California." The applica must call for all required inspections. Complete drawing on reverse side. Date- Title: Signed X FOR DEPARTMENT USE ONLY � _. ...' pate Area ix Application Accepted by pate Date Final Inspection by , i Pit or Grout Inspection by Additional Com Writs: O Manteca 823-7104 ❑ Tracy 835-6385 ,. ❑ Stk- 466-8781.--*-t= :❑ Lodi 369-3621 Stk.,.CA 95201 I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, CK RECEIVED BY DATE PERMIT`NO. FEE AMOUNT DUE AMOUNT REMITTED CASH INFO _ +.EH 13-24(REV.s/N sl EH 14-28 - —