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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (2t79) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) application is App in Coun Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Application is hereby made to the San Joaq n Local Health District for a permit to construct and/or install the work herein described. h made in compliance with San Joaquin f Local Health District. : PM City — Lot Size Job Address Phone i` Address p Owner's Na CLS fI 535 Phone -� �U iI License No.__�--- U' Address DESTRUCTION ❑ Contractor WELL REPLACEMENT ❑ NEW WELL ❑ OTHER �+0 ),jr � 4 ' TYPE OF WELLIPUMP: SYSTEM REPAIR ❑ � IN PUMP INSTALLATION ❑ i _�_ DISPOSAL FLD. PROP. LINE Jcx� SEWER LINES �� ' PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK Lam` — AGRICULTURE WELL OTHER WELL FOUNDATION i/ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION pia. of Well Casing INTENDED USE 1— Dia. of Well Excavation ❑ Open Bottom L�'141anteca ❑ industrial Specifications [(3�ravel Pack ❑ Tracy Type of Casing11 ,�ti�C�lFk7� �Domesticl nvate — Type of Groutpa.._� — I� Other F.1 Delta Depth of Grout Seal IQ GQp�— 1 l-1 Public Surface Seal installed by I Irrigation —.-Appro x. Depth l I Eastern State Work Done Type of Pump �� N.P. Repair Work Done ❑ � q � t Sealing Material Itop 50'1 r 1 Well Destruction ❑ Well Diameter RnLk \\ j Depth Filler Material IBelow 50'1 \ fl available within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION I i If I I DESTRUCTION i I INo septic system permitted if public sewer is Installation will serve: Residence i Commercial, Other 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 IMfg Method of Disposal I PKG, TREATMENT PLT. ❑ I Foundation Property Line '. Distance to nearest; Well i Total length/size f LEACHING LINE ❑ Na. & Length of lines Property Line ❑ Distance to nearest: Well Foundation p y I FILTER BED I ! Number 'I SEEPAGE PITS I 1 Depth Size Property Line L� Distance to nearest: Well Foundation p SUMPS f " 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 h In rules and regulations of the San Joaquin Local Health Di'strict.g work for Home owner or lice nssuc gmanne gas torbecome subject workmanIsrtify that in the compensation lawsoof California."Contractor's 1lhiring or sub-cont act nglsignatus all ore employ any person certifies the following: u certify that ss the performance of the work for which this permit is issued, I shall employ persons subject to workman's compen - tion laws of Calif E ` The applicant ust all for all r ire pacti Complete drawing on reverse side. Title: �� Date: C/ Signed X �` FOR DEP Date TMENT USE ONLY f 1 Area Application Accepted by Date F Pit o Grou Inspection by Date � � Final Inspection by Additional Comments: fl Stk 466-6791 ❑ Lodi 369-3621 ❑ Manteca 823-7104 fl Tracy 835.638 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk-, CA 95201 DATE PERMIT ND. FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY INFO +.EH 13-24 IREV.1/H 51 r. EH 14-29 .