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k APPLiCATION.FOR PERMIT SAN JOAQUiN LOC' AL DISTRICT �] 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 465.6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED F {Complete in Triplicate) F ` Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the made in compliance with San Joaquin Coun Local Health fianceDistric „ - Ordinance No,549 for sewage or No. 1862 for wail/pump and the Rules and Regulations of he San IlJoaqu n i Job Address � '- �':1::= � C �� ' .., w 1 S L City G D Lot Size ' Od d VA� Owner's Name PM �� - v � Address Contractor - Phone TYPE OF WELL/PUMP: Address NEW WELLLicense No. Phone PUMP INSTALLATION E3 SYSTEM REPLACEMENT L] _ DESTRUCTfON F_1 h DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ . �� SEWER LINES OTHER ❑ FOUNDATION`� AGRICULTURE WELL �~ DISPOSAL FLD. PROP. LINE INTENDED USE OTHER WELL TYPE OF.WELL -' PROBLEM AREAPITS/SUMPS EJlnd ❑ Open Bottom ❑ usM.i �� CONSTRUCTION SPECIFICATIONS Manteca ❑ Domestic/PrivateDia. of Well Excavation ❑ Gravel Pack ❑ Tracy . Dia. of Well Casing C3 Public Q Other Type of Casing El Irrigation ❑ Delta Depth of Grout Sea! Specifications Repair Work Done ❑ Approx. Depth ❑ Eastern Surface Sea] installed by Type of Grout T----Approx. of Pump �! H P. ' Well Destruction " ❑ Well Diameter x� —State Work Done Sealing Materia! (top 50')__ tl r Depth TYPE OFiller Material (Below 501) [Y F SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION T ' t fNa septic system (�^ installation will serve: Residence permitted if public sewer is Commercial - ailable within 200 feet.) Number of living units: Other Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK -- ' ❑ Type/Mfg �* _ Water table depth � PKG. TREATMENT PLT. ❑ Capacity No- Compartments Distance to nearest: We1f" Method of Disposal " € Foundation Property Line i LEACHING LINE ❑' No; far Length of lines FILTER BED Total length/size ❑ Distance to nearest: Wel! Total Property Line SEEPAGE PITS Q` Depth SUMPS Size Number ❑ Distance to nearest: We" DISPOSAL PONDS ❑ Foundation Property Line i hereby certify that i have prepared this application and that the work will be done in accordance with San Joaquin count ordinances, rules and regulations of the San Joaquin local Health District. Home owner or licensed agent's signature certifies the following: Y antes, state laws, and employ ie any person g such manner i to become subject to workman's in laws of California."Contractor's hiring or sub-contracting signature "I certify that in the performance of the work for which this permit is issued, l-shall not certifies the following: �^: g: "f certify that in the performance of the work for which this permit is issued, f shall employ persons subject to workman's compensa- tion tion laws of California." ------------- The applicant must call for all required inspections:Complete drawing om reverse side. Signed X Title- FOR itle y Date: FOR DEPARTMENT USE ONLY Application Accepted by J Date Pit or Grout Inspection Area Date FiV inspection b Additional Comments: =� _ Date ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823.7104 ❑ Tracy 835 6385 Applicant- Return all to: EnvironmentaI ealth Permit/Services 1601 E. Hazelton Ave., P.O. ox 20()8, Stk., CA 95201 f FEE �� P � , INFO AMOUNT DUE AMOUNT REMITTED C ' RECEIVED 6Y DATE EM 13-24(REV.t i x sr PERMIT•NO. 'p EH 14-26