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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE.,.STOCKTON, CA a Telephone (209) 466-67810t� i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED- , 11 (Complete in Triplicate) i v F t�... wo perm Application is hereby a e to the San JoaquinCountyOrdinalnce No.HealthD549 for sewage or INo. 1862 for well/to constructdpump and the Rules and Regulations of the Sanl J aquin made in compliance with Health District. c . City �Lo t Job Address 'Size J PM /i Phone `� �� Address Owner's Name Address License No. Contractor Ad �—Phone TYPE OF WELL/PU P: NEW WELL ❑ WELL REPLACEMENT L03 DES TRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS IO II FOUNDATN AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Industrial Specifications LI Domestic/Private 1-1GravelPack ❑ Tracy Type of Casing Depth of Grout Seal Type of Grout [IPublic ❑ ❑ Delta Other �- 1 --Approx. Depth ❑ Eastern Surface Seal installed by 1 El State Work Done Repair Work Done ❑ Type of Pump H.P. Sealing Material (top 50'1 ` �] Well Destruction P- Well Diameter Filler Material (Below 50`1 f DepthIII l TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO Nailablelwithin e200 feet.) if public sewer is Installation will serve: Residence�� Commercial_ Other j Number of living units: Number of bedrooms yllater table depth Character of soil to a depth of 3 feet: �. L ((� No. Compartments SEPTIC TANK Type/ Capacity t Method of Disposal I PKG. TREATMENT PLT. ❑ I ' �Foundatian 's Property Line Distance to nearest: Well r = :� t _f r I 1 t Total length/size— LEACHING ength/size LEACHING LINE ❑ No. & Length of lines Property Line FILTER BED ❑ Distance to n �,.,,,.�..-- .,earest: Well- Foundation i ❑ Depth's Size Number ` 1 SEEPAGE PITS Foundation Property Line SUMPS EJ Distance to nearest: - Well r 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 a rules and regulations of the San Joaquin Local Health District. that the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: "I certify t a signature employ any person in such manner as to become subject to workman's compensation laws-Of Califoinia-" Contractor'snsrsubject t workman's sub-contracting the following: "I certify that in the performance of the work for which this-permit s issued;I shall employ pe tion laws of California." F The applicant ust call for all required ins ctions. C fete drawing on reverse side. r� Title: Date: x Signed - FOR DEPARTMENT USE ONLY Area Application Accepted b e 7 Pit or Grout Inspection ,pate Final Inspection by Dat f" Additional Comments: ❑ Stk 466-6781 ❑7 L di 369 3621 ❑ Manteca 823-7104 ❑.Tracy 835 6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 RECEIVED By DATE 'PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED INFO + EH 13-24(REV.1/&5) r EH 14-26 .� _ - .....