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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Zationis Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) made to the San Joaquin Local Health District for a permit to construct and/or install the work hereindescribed. This application is Appeby ump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/p Local Health District. � i�/� �n CityAke-- — Job Lot Size Z Address P— �� Phone /G/ d G'// **9 Address 7 Owner's Name f License No. Phone Address Contractor WELL REPLACEMENT ❑ DESTRUCTION NEW WELL LD WELL ❑ TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE k SEWER LINES �— PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK �— AGRICULTURE WELL OTHER WELL FOUNDATION �--- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing Dia. of Well Excavation I ❑ Industrial ❑ Open Bottom ❑ Manteca Specifications 1. Type of Casing ❑ Domestic/Private Ll Gravel Pack ❑ Tracy Type of Grout — i-1 Public ❑ Other Cl Delta Depth of Grout Seal ; �_Approx:Depth I I Eastern Surface Seal Installed by t I I Irrigation H P State Work Done — Repair Work Done ❑ Type of Pump --- IIII Well Destruction El Well Diameter Sealing Material (top 50'1 Depth �S" Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION (a REPAIfllADDITION t 1 DESTRUCTION I ! (No septic system permitted if public sewer is available within 200 feet.) Commercial f Other �— Installation will serve: Residence /; I Number of living units: Number of bedrooms Water table depth W I Character of soil to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal I PKG, TREATMENT PLT. ❑ Foundation Property Line Distance to nearest: Well k i Total length/size LEACHING LINE ❑ No. & Length of lines Foundation Property Line FILTER BED LlDistance to nearest: Well J I Depth I Sire Number SEEPAGE PITS Foundation Property Line SUMPS Cl Distance to nearest: Wel! DISPOSAL PONDS ❑ i I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, 71shall and rules and regulations of the San Joaquin Local Health District. Home or licensed agent's si the following: "I certify that in the performance of the work for which this permit is isssignature not rnia." Contractor's e oy-any p rson in such man r as to.becomes ofthework foswh chin s perm tnsation is issueds of , I shall employ perrsonslring suti eat tobworkman-contract1scompensa- ifie9,tfie f Ilowing: "I ceRify atin`tte" on laws o alifornia." he ap ant must call for aN requir i s coon Complete ra o reverse side. y Date: fined ' FOR DEPME E ONLY a� Date - Area g� Application cceptad by do Dated. �- '' - _ Final Inspection by , Pit or Grout Inspection b Date, Additional Comments: ❑ 5tk 46fi-6781 ❑ Lodi 369-3621 El 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 PERMITNO. FEE AMOUNT DUE AMOUNT REMITTED ' M INFO ..EH 13-21IREV.iin5l EH 1426