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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL-ION AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) k Application is hereby made n the San Joaquin ou County ord ordinance No.549 for sewage ealth District for a or It to Na 1862 and/or install the work and the Rules and herein clesc Regula of the San Joaquin L made in compliance with San JoaquintY Local Health District. / City " I' Lot Size A�fPM Job Address Phone Address Address Owner's Name Contractor i&� p Address aaL^' 'License Nom- =�haneA �� TYPE OF WELL/PUMP: NEW WELL 71 WELL REPLACEMENT F1 DESTRUCTION ❑ REPAIR ❑ OTHER PUMP INSTALLATION ❑ SYSTEM 11 SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK � FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing 11 Industrial ❑ Open Bottom [1 Manteca Dia. of Well Excavation Specifications Type of Casing C7 DamesticlPrivate L] Gravel Pack ❑ Tracy Depth of Grout Seal ' Type of Grout - (-I Public FI Other F1 Delta _Approx. Depth I 1 Eastern Surface Seal Installed by j I I Irrigation — State Work Done I Repair Work Done ❑ Type of Pump Seal I } Well Destruction ❑ Well Diameter Sealing Material flop 50'1 ,- Depth Filler Material 16elow 501' TYPE OF SEPTIC WORK: NEW 1NSTALLATION I l REPAiRIADDITION DESTRUCTION I i avfailabpticle system m reined if public sewer is h� eet Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Water table depth _ Character of soil to a depth of 3 feet. . No. Compartments SEPTIC TANK v F1 'Type/Mfg Capacity I Method of Disposal ` PKG. TREATMENT PLT. ❑ � k Distance to nearest: Well Foundation � Property Line t LEACHING LINE No. & Length of lines _ Total length/size FILTER BED ,❑ Distance to nearest: Well 5D f Foundation_112Z_ Property Lindh SEEPAGE PITS A LDepth Size `� r Number SUMPS Cl Distance to nearest: Well L�$ • Foundation — 14) Property Line/ r , ,•st DISPOSAL PONDS ❑ h7ereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I rules and regulations of the San Joaquin Local'Health Dilmict. T a - Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not person n such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature employ any i certifies the person I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- g. tion laws of California." ", The applicant must call for all required inspections. Complete drawing on re side. a Title:,' Date: Signed X _ k FOR DEPARTMENT USE ONLY 7 �� Date Area�S Application Accepted by ''� ,�-�t� o.i. Date :;2,-J— L Final Inspection b Date —[- or Grout Inspection by a .. Additional Comments: © Stk 466-6781 © Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEEAMOUNT DUE AMOUNT REMITTED RECEIVED BY GATE PERMIT NO. INFO ^r r.EH 13-24(REV.I/N 5) O EH 14-28