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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ;1 PERMIT EXPIRES 'I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Jo quin County Ordinance No.549 for sewage or No. 1862 forwell/pump and the Rules and Regulations of the San Joaquin Local Health District. II city Lot Size �� r �'s� PM ity Job Address i C Owner's Name r +x Addresses'r I Phone Contractor's Name L License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ S> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �,DISTANCE TO NEAREST:SEPTIC TANK _ _�_ _,_ SEWER,LINES r DISPOSAL FLD. PROP. LINE {_. _,u_� r FOUNDATION` AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O ❑ Industrial El Open Bottom ❑ DAantecai Dia.';of Well Excavation ' ' •' I Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy t--Type of Casing I � 1 A Specifications Llii ;.�;�...r..�, ri [I Public C1 Other 11 Delta ( _Depth of Grout Seal I Type of Grout Surface#Seal Installed by ! ElIrrigation _--Approx. Depth ❑ Eastern • ` t R Repair Work Done ❑ Type of Pump H.P. State Work'Done Well Destruction ❑ Well Diameter Seating Material !top 501 FE ) s Depth Filler MaterialrlBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION TRUCTION ❑ (No s,pticisystem permitted if public sewer is • Ii available within 200 feet.) Installation will serve: R idence 'Commercial_ Other Number of living units: Number o bedrooms { �` J. I _ t Water table depth Character of soil to a depth of 3 feet:,! I SEPTIC TANK CJ Type/Mfg Capacity No. Compartments ' { i r Method of Disposal PKG.,TREATMENT PLT. ❑ I Distance to nearest: Well Foundation Property Line — r Total len ; ;th/size LEACHING LINE Si—o. & Length of lines j g FILTER 8ED ❑ Distance to nearest:--W611 Foundation� Property Line SEEPAGE PITS ❑ Depth Size" ` '` Number Foundation__J—Q --Property Line SUMPS 6�- [7istance-to-nearest: Well DISPOSAL PONDSe—[7-" I hereby certify that I-Qve;prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of'tl a San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work or which this permit is issued, I shall not ' ompensation laws of California."Contractor's Miring or sub-contracting signature employ any person in.such manner as to become subject to workman's c certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employipersons subject to workman's compensa- �„tts ws'of Californ! . ' 'w The applic u call r a requi a in cti . Complete drawing'. reverse s' e. Signe Title: Date:� � FOR DEPARTMENT USE ONLY r" Application Accepted by -- Date L Area Pit or Grout inspection by Date f Final inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 36&3621 ❑ Manteca 823-7104 'i ❑ Tracy 835-6385 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PER MIT`NO. INFO /�p I uJ [-l10 7 'T f 13 1� + EH 13-24 MEv,10/831 Ill ! EH 14-28 j ..