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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephorle (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED 1 (Complete in Triplicate) lication is Application is hereby made to the San Joaquin Local Health District for a per to construct and/or install the work herein described. This app made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Locai Health District, 11t f ��G Lot Size I PM City Job Address ��} ��, Phone w Owner's Name ✓"s_� M L �O- Address EP', dress Phone�� Contractor DESTRUCTION ❑ NEW WE WELL REPLACEMENT ❑ � TYPE OF WELLIPUMP: SYSTEM REPAIR 11OTHER ❑ PUMP INSTALLATION ❑ rSEWER LINES PITS/SUMPS DISPOSAL FLDLTC[l! ►"ROP. LINE-' DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL FOUNDATION s INTENDED USE TYPE OF WELL PROBL_ E� M AREA CONSTRUCTION SPECIFICATIQNS pia. of Well Casing ` Dia. of Well Excavation ❑ Industrial ❑ Open Bottom ❑ Manteca 1�� Specifications t T e of Casing \ Domestic/Private -Gravel Pack ^,Tracy YP '- Type of Groutt�� Y F1 Other I ❑ Delta Depth of Grout Seal IIIIIt'1 Public ��// Surface Seal Installed by I I irrigation APProx. Depth t I Eastern H.P. State Work Done _�-- Repair Work Done LD Type of Pump, Sealing Material (top 501 Well Destruction Gl Well Diameter _ Depth ' Filler Material (Below 501 � TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIRlADDITION l 1 DESTRUCTION I I (NailabPelwrted it public sewer is hin 200 feetsys em it� \1 �_-- Installation will serve: Residence Commercial— Other � a Number of living units: Number of bedrooms Water table depth i Character of soil to a depth of 3 feet: Capacity— No. Compartments ( SEPTIC TANK ❑ Type/Mfg I I Method of Disposal PKG. TREATMENT PLT. ❑ Property Line Distance to nearest: Well Foundation I • Total length/size LEACHING LINE D No. & Length of lines FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS V I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line } 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, an rules and regulations of the San Joaquin Local Health Di§trict. 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, I s a not ring or signature employ any person in such manner as to become subject to workman's compensation laws of California." Contraceonslsub'ect to woorkman1scompensa- certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ p 1 ' tion laws of California." I _ The applic m t for all req -r d inspections. Complete drawing on a rse sid Date: � Title' Signed X FOR DEPARTMENT USE ONLY r R i y-+ pate Area Application Accepted by I Pit or Grout Inspection by _�-- Final Inspection by Date Date Additional Comments: 835-6385 ( ` ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK RECEIVED BY DATE PERMI EEE T NO. AMOUNT DUE AMOUNT REMITTED CASH INFO a EH 1324(REV.i EH 14-26