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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 1 APP Irction is he+eby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made a compliance with San Joaquin Gouniy Ordinance No. 549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. I City Lot Size PM Job Address ! (O C¢ 1 Phone Address Owners Name E 7 s0 License No. W.--Phone— Contra f Contra i Address NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION TYPE OF WELL/PUMP: SYSTEM REPAIR L] OTHE ❑ PUMP INSTALLATION 11 ! SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: .SEPTIC TANK PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL I _ INTENDED USE TYPE OF-WELL PROBLEMAREA `CONSTRUCTION SPECIFICATIONS Dia. of Well Casing Dia. of Well Excavation El Industrial ❑ Open Bottom ❑ Manteca Specifications Type of Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Depth of Grout Seal Type of out n Other ❑ Delta M Public Surface Seal Installed by t I l Irrigation —.-Approx. Depth l I Eastern H P. State Work Done Repair Work Done ❑ Type of Pump Sealing Material Itop 501 Well Destruction ❑ Well Diameter Depth i Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 REPAIRIADDITION [ I DESTRUCTION I ! aNailablpe+ permitted if public sewer is within 200 feet.) Installation will serve: Residence�. Commercial Other_�--- Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ Property Line I Distance to nearest: Well .Foundation LEACHING LINE ❑ No. &l Length of lines ; Total length/size r � L Foundation Property Line FILTER BED ❑ Distance to nearest: Well - I ` Number SEEPAGE PITS C I Depth Size rFoundation Property Line r SUMPS L-1 Distance to nearest: Well DISPOSAL PONDS ❑ I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state'fla�ws� d an rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "l certify that in the performance of the work for which this permit is issued;g sghalt.not - employ any person in such manner as to became subject to workman's compensation laws of California." Contractors hiring or sub- acting sr nature.: +. certifies the following: "I certify that in the performance of the work for which this permit is issued, i shall employ persons subject to workman's compensa- tion laws of California." i The applicant mu c I far all r vire pections. Complete drawing on reverse side. f Title: _— �' Date: Signed X 3' OR DEPARTMENT USE ONLY - Date Area Application Accepted by Pit or Grout Inspection by Date Final Inspection b) Date /77 Additional Comments: EJ 466-6781 ❑ Lodi 3fi9 3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health.Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 AMOUNT REMITTED C RECEIVED 9Y DATE PERMIT NO. FEE AMOUNT:DUE H INFO s,yn.. +.EH13-24(REV.+/K5) EH 14-26 Ste'"