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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT F Y 1601 E. HAZELTON AVE., STOCKTON, CA I ! Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �- (Complete-in Triplicate) +* + r .1,nrea �. r Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described- This application is o.549 for-sewage or No. 1862 for well/pump.and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance N Local Health District'."' t +�w � � x City of Size :5 PM Job Address l – 1p'd Phone Owner's Name' V address Contractor Address License No. Phone W ELL!PU MP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPEi�F OTHER PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ O DISPOSA PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ER WELL PROP. LINE FOUNDATION AGRICULTURE WELL UMPS INTENDED UAu WELL PROBLEM AREA C UCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrialtom_,�LD Mante Dia. of Well Excavation Type of Casin Specifications ❑ Domestic/Privateck 1r.+ racy yp g Type of Grout ID-Publict ❑ Delta Depth of Grout Seal yp ❑ Irrigation . Depth d Eastern Surface Seal Installed by Repair Work Donp H.P. State Work Done— Well Des ion ❑ Well DiameterSealing Material (top 50'! Depth I Filler Material {Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (Neilsepti system retitled if public sewer is . _ 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: No. Compartments SEPTIC TANK >( Type/Mfg Capacity Method of Disposal !� PKG. TREATMENT PLT. ❑r I Distance to nearest: Well Foundation Property Line Total length/size LEACHING LINE Q No- & Length of lines -� Property Line FILTER BED ❑, Distance to nearest: Well Foundation Size / Number SEEPAGE PITS ❑ Depth Property Line SUMPS - ❑ Distance to nearest: Well Foundation i 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 rules and regulations of the San Joaquin Local Health District. this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which employ any person in such manner as to.becomesubiect to'workman's-compensation-laws of•California:" Contractor's hiring or sub-contracting signature F certifies the following:"i certify that in the performance of the work for which this permit is issued,I shall employ persons subiect to workman's compensa t tion laws of California-" The applicant must call for all required inspec s. Complete drawing on reverse side. _ _ rt / Date: Signed X Title: , FOR pEPARTMENT USE ONLY',. 13 f _ Date + Area 03 F Application Accepted by Pit or Grout Inspection b Date T Final Inspection by4ff&t Dat F Additional Comments: ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 104 ..❑ Tracy 835-6385 Applicant Return all copies to: Enirironmantal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FEE CK `' RECEIVED BY DATE PERMIT NO. AMOUNT DUE AMOUNT REMITTED INFO j .lLt I + EH 13.24 IpSV.i�a 5l �0 �� ... �J ✓`�i 4 [ tE L EH 14.28 .. .._. _.