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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA „ Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) cribed.This application is Application is hereby made to tha San Joaquin Local Health District for a permit to construct and/or install the work herein des made in compliance with San Joaquin County Ordinance No, 549 for sewage or No. 1862 for welVpump and the Rules and Regulations of the San Joaquin Local Health District. s! AU f E, //11 City Al r 0)_N Lot Size PM t Job Address Owner's Name - ' Address I7 Phone Address Phone Contractor License`,Nv. l TYPE OF LL/ P: I NEW WELL WELL REPLACEMENT 1:1 DESTRUCTION LJ PUMP INSTALLATION I< SYSTEM REPAIR ❑ OTHER ❑ DISPOSAL FLD. DISTANCE TO NEAREST: SEPTIC TANK �I�Q-.�'SEWER LINES PROP. LINE 1000 f` it FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S � l! Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Industrial @Q L Specifications R!rDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing S F1 1 Public H Other f 1 Delta Depth of Grout Seal Type of Grout - I I Irrigation Approx.,Depth t I Eastern Surface Seal Installed by F \ State Work Done ' Repair Work Done ❑ Type of Pump _.�(,6 H•P. L Well Destruction _ © Well Diameter ' Sealing Material (top 50') d Dep Filler Material (Below 50') th TYPE OF SEPTIC WORK: NEW WSTALLATION l 1 REPAIRIADDITION I I DESTRUCTION I I INO septic thin system permitted if public sewer is Installation will serve: Residence_ Commercial Other a Number of living units: �N Number of,b'edrooms .i ..,w ...r. Water table depth Character of soil to a depth of 3 feet: � _ —� " ._ �No:Cbrnpartments l SEPTIC TANK ❑ .Type/Mfg Capaaty , l `-'► -; "� Method of Disposal PKG. TREATMENT PLT. ❑ r Distance to nearest: Well '��;Foundation r r I '-;;Property Line ' f Total length/size : I a LEACHING LINE El No. & Length of lines ,w ' FILTER BED ❑ Distance to nearest: ` Well Foundation :`'`�4 F Property Line Y J=Number SEEPAGE PITS 1 1 Depth Size ' Property Line SUMPS Cl 'Distance to nearest: Well Foundation r' i h DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin couiy ordinances, state laws, an �. rules and regulations of•,the San Joaquin Local Health District. ridt Home owner or licensed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature Y certifies the following: '9 certify that in the performance of the work for which this permit is issued, I shall employ per ns subject to workman's compensa tion laws of California." i The applicant ust a for all required nspection . Complete drawing an reverse side. 1 Date: I Signed X _ Title: ! FOR DEPARTMENT USE ONLY Aby Data AreaApplication Accepted Date v- Final Inspection by ��'� - Date Pit or Grout inspection , J Additional Comments: i ❑ Stk 466-6781 ❑ Lrodi 369-3621 Manteca 623-7101 ❑ Tracy 835-6385 I Applicant Return all copialJ��to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,,P.O. Box 2009, Stk., CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO r , p v W-1 + EH 13-24(REV.185) zs * - , EH 14- - / - r