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APPLICATION FOR PERMIT § SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED F (Complete in Triplicate) th District for a permit to construct and/or install the work herein described. This app I Application is hereby made to the San Joaquin Local Healtcation is 9 for sewage or No. 1862 for wel4/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.54 Local Health District, l i ,.� City ,tot Size _ '' PM Job Address /. r y� —F S ` Phone OC ' Owner's Name Address U - �ry Contractor' Address K License No-- • Phone TYPE 't WELL/PUMP: NEW WELL F) r WELL REPLACEMENT ❑ DESTRUCTION ❑ i SYSTEM REPAIR ❑ ; OTHER ❑ PUMP INSTALLATION ❑ .- ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -,DISPOSAL FLD. PROP. LINE , FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA �CONSTRUCTION SPECIFICATIONS pia. of Well Casing ' 11 Industrial ❑ Open Bottom EJ Manteca Dia. of Well Excavation of Casing Specifications 5 ` ❑ Domestic/Private ❑ Gravel Pack LJ Tracy •��-- -Type g Type of Grout—.-- Approx. rout — E {-1 Public f I Other ❑ Delta Depth of Grout Seal I Irrigation Approx. Depth I I Eastern Surface Seal Installed by k State Work Done Repair Work Done El Type of Pump H.P. erial„Itop 50'1.. f Well Destruction ❑ Well Diameter „- Sealing Mat "r Depth t Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I l avadabNo perwthin 200 feetstem 't�ed if public sewer is t Installation will serve: Residence Commercial Other_ Number of living units: Number of bedrooms -.— t f Water table depth I Character of soil to a depth of 3 feet: ' ' Capacity Compartments SEPTIC SEPTIC TANK L3Type/Mfg i _ Method of Disposal PKG. TREATMENT PLT. ❑ .da —� i Distance to nearest: Well +Foundation!t! Property Line Total length/size I LEACHING LINE ❑ No. & Length of lines - FILTER BED ❑ Distance-to-nearest: Well C— Foundation Property Line f.F MMSPO�A E PITS l I Depth Size Number❑ Distance to nearest: Well�� Foundation Property Line__r'PONDS ❑ r 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. ify that in the performance of the work for which this permit is issued;'/shall not Home owner or licensed agents signature certifies the following: "I cert employ any person in such manner as to become subject to workman's compensation laws of California.” Contractor's hiring or sub-contracting signature ued, I shall employ persons subject to workman's compensa certifies the following: "I certify that in the performance of the work for which this permit is isste tion laws of California." f' } The applicant ust for all req red spections. Compl drawing on se side. f I� (J Title: Da Signed X ! i I FOR DEPARTMENT USE ONLY y f �.,Q [ 3 2 2 t7 f� Area L / Application Accepted by - o. a Date q Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 13 Tracy 835-&385 i ` Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 4 4 CK RECEIVED BYjDATE PERMIT NO.FEE AMOUNT DUE AMOUNT REMITTED CASH INFO r EH 13-24/REV.5/x51 •� f r EH 14"26