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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 456-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (Complete in Triplicate) application is ' Application is hereby made to the San Joaquin Local Health District for permit to construct and/or install the work herein described.This made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules anRegulations of the San Joaquin Local Health District. t a U �L t Size PM�-- +rj City - Job Address ((�f Phone to Address Owner's Name License No.—.Phone_ Contractor Address WELL REPLACEMENT C01 DESTRUCTION LJ k NEW WELL ❑ OTHER 11TYPE OF WELL/PUMP: _ SYSTEM REPAIR ❑ PUMP INSTALLATION C) DISPOSALFLD. PROP. LINE k SEWER LINES ��-- PITSISUMPS DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL • FOUNDATION �--- Y n Y F WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing INTENDED USE TYPE Ox`} o- Dia. of Well Excavation Ci Industrial ❑ Open Bottom ❑ Manteca Specifications i ❑ Tracy Type of Casing _ ❑ DomesticlPrivate ❑ Gravel Pack Type of Grout p t F1 Delta Depth of Grout Seal ['1 Public [] Other _Approx. Depth l l-Eastern -_ _,Surface Seal.installed by I 1 Irrigation-^� H P State Work Done j Repair Work Done ❑ Type of Pump -- -- Sealing Material(top 501 a well Destruction E3 Well Diameter _�.--- Depth Filler Material (Below 50') vailable within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIRlADDITION [ i DESTRUCTION 1 o septic system permitted if public sewer is ' t , Commercial Number Other installation will serve: Residence 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. ❑ Foundation Property Line Distance to nearest: Wel[ Total length/size LEACHING LINE ❑ No. & Length of lines Property Line FILTER BED" ❑ Distance to nearest: Well Foundation Number I4 I Depth Size—� SEEPAGE PITS Foundation Property Line SUMPS Cl Distance to nearest: Well 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.g y that in Home owner or licensed agent's signature certifies the ect Ito ing: "I workman's compensation laws Califorrnia." Contractor's rhir gr or sub-contracting signs permit is issued, I atuore employ any person in such manner as to become sub) p per sons subject to workman's compensa- certifies the following: "I certify that in the performance of the work for which this ermit is issued, I shall employ P tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. _ e Date: Title: Signed X k FOR DEPARTMENTifSE ONLY or Date Area r Application Accepted by Date " Pit or Grout Inspection by Date Final Inspection by g Additional Comments: 3�� • i ❑ Stk 466-6781 ❑ Lodi 369 3621 ❑ Manteca 823 7104 ❑ Tracy 835-6385 Applicant - Saturn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Sox 2009. Stk., CA 95201 CK RECEIVED BY DATE PERMIT NO, FEE AMOUNT DUE AMOUNT REMITTED CASH — :. INFO —&-9 7 i sm /TA } v +.EH 13-24(REV. /n 5iJ1 r EH 14-29,