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APPLICATION,FOR PERMIT N SAN JOAQUIN LOCAL HEALTH DISTRICT a� "� 1601 E. HAZE T ON AVE.; STOCKTON, CA j Telephone (209) 4656-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED '--. , (Complete in-Triplicate} w I for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Application s hereby made to the San Joaquin Local Health District for a gpermit to construct and/or install the work herein des cribed.'This application is made in compliance with.San Joaquin County Ordinance No. Local Health District. 100 PM.- s Cid .. Lot Size Job Address ! ,W/ Phone `�— �a 4 -Address Owner's Name i r. License No. Phone._ Address Contractor WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF WE L' /PUMP: NEW WELL ❑ OTHER ❑ SYSTEM REPAIR ❑ PUMP INSTALLATION ED SEWER LINES DISPOSAL FLD. PROP. LINE � DISTANCE TO NEAREST: SEPTIC TANK � AGRICULTURE WELL OTHER WELL PITS/SUMPS FOUNDATION TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS INTENDED USE --E— Dia. of WetlCasing _ k ❑ Industrial ❑ Open Bottom ❑ Manteca �.. ...�Dia. of Well Excavation. ! Specifications ❑ Tracy Type of Casing L] Domestic/Private 71 Gravel Pack Depth of Grout Seal i Type of Grout ❑ Other ❑ Delta 4 k [71 Public i Surface Seal Installed by ❑ Irrigation _J�pprox. Depth ❑ Eastern State Work Done— I H,P f Repair Work Done ❑ Type of Pump Sealing Mater.ial.(top 50'1".; Well Destruction ❑ Well Diameter R Depth Filler Material (Below 50'5 I } vailable within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No€septic system permitted if pubic sewer is • r installation will serve: Residence Commercial, Other s Number of living units: Number of bedrooms _J Water table depth r Character of soil to a depth of 3 feet: Capacity . No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ Property Line ' Distance to nearest: Well . Foundation P rtl' x 4 Total length/size i LEACHING LINE ❑ No. & Length of lines Foundation Property Line" ti FILTER BED ❑ Distance to nearest: Well k ❑ Depth Size Number SEEPAGE PITS Property Line SUMPS ❑- Distance to nearest: Well foundation DISPOSAL PONDS � ❑ I hereby certify that 1 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. art that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: "I c such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature employ any person in ss the performan q ce of the work for which this permit is issued,I shall employ persons subject to workman's compensa- certifies the following: certify that tion laws of California." The applicant must call for all required inspections. Complete drawing Signed X� � ��;,J3`� Title:*— Date: i i FOR DEPARTMENT USE ONLY Area Date y r "Date S r Application Accepted by !2 CJ ' Final Inspection by Date Pit or Grout Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca ..823-7104 ❑ Tracy 835-6385 lth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Applicant- Return all copies to: Environmental Hear K RECEIVED BY DATE PERMIT NO. FEE 7 AMOUNT DUE AMOUNT REMITTED CA(S�H ��y�/j INFO 1 1 / 137^"l 1 O + EH 13-24(REV.1/a 5) _ EH 1120