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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEILTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) /or install the work . This cation is Application is hereby made to the aJoaquin Local calne Health District for sewage or it t 1 on forcwe I�pump and the Rules and(Regulations of he San r Joaquin made in compliance with San Joaquin Local Health District. : q �� ' Lot Size PM �( City Job Address Phone Address Owner's Name Contractor. -- Address License �L�-�-�phon�l NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ OTHER ❑ PUMP INSTALLATION CJ SEWER LINES �—_ �— DISPOSAL FLD. PR DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL, PITS/SUMPS FOUNDATION AGRICULTURE WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPE ICA IONS pia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well nation. Specifications I T,pe•of Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Depth of-Grout Seal . Type of Grout ❑ Other ^]� ❑,Delta M Public Surface Seal Installed by I I irrigation �.-ApprI.. Depth stern State Work Done— H.P. Repair Work Done ❑ Type of Pu� Sealing Material flop 50'1 Well Destruction- Diameter Depth. I Filler Material (Below 501 ITION I ! QESTRUCTIO am TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDavailablelwith in 200 feetitled it public sewer is C installation will serve: Residence "Commercial, Other Number of living units: NU mber of bedrooms t Water table depth Character of soil to a depth of 3 feet: Na. Compartments SEPTIC TANK ❑ Type/'Mfg Capacity tr "`Method of Disposal PKG. TREATMENT PLT. ❑ Foundation Property tine �\ Distance to nearest: Well . Total length/size LEACHING LINE ❑ No. &Length of lines Foundation Property Line FILTER BED ❑ Distance to nearest: Well I Size Number SEEPAGE PITS I } Depth, ! 0 Distance to nearest: Well Foundation Property Line f SUMPS 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- she not 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 employ any person in such manner.as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- certifies the following: tion laws of California." > .. # I The applicant t call for all required ins tions.-Complete,drawing on raver side. �i Title: Date: Sig FOR DEPARTMENT USE ONLY DateArea N Application Accepted by ' Date Finf-1 spection by C/ Date k Pit or Grout Inspection by 1 Additional Comments: r ❑ 5tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 i GK RECEIVED BY DATE PERMIT'NO. I FEE AMOUNT DUE AMOUNT REMITTED CASH INFO y EH 13-24(REV.r/R 51 EH 14-28