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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES YYEAR FROM DATE ISSUED (Complete in Triplicate) and/or install the work herein described. This application is Application is heiehy made to the San Joaquin Local Health District for a permit to construct made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for weii/pump and the Rules and Regulations of the San Joaquin Local Health District. i �j r. City Lot Size t PM Job Address f ^ Address r f� r n. Phone Owner's Name � -� _ pJ If Contractor � Address License No 3A21X Phone �Ua DESTRUCTION 17TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ PUMP INSTALLATION F1 SYSTEM REPAIR ❑ OTHER 171 F DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE f FOUNDATION AGRICULTURE WELL OTHER WELL ?ITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well I Casing t ElIndustrial ❑ Open Bottom ClManteca Dia. of Well Excavation Type of CasingSpecifications © Domestic/Private ❑ Gravel Pack ❑ Tracy I FI Public Other FI Depth of Grout Seal Type of Grout ❑ I I Irrigation -Approx. Depth i I Eastern Surface Seal Installed by - Repair Work Done ElType of Pump H P State Work Done_ I Well Destruction ❑ Well Diameter -- Sealing Material (top 501 1 !111 Filler Material (Below 501 -- Depth TYPE OF SEPTIC WORK: NEW INSTALLATION IV REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is p, available within 200 feet.) Installation will serve: Residence Commercial "— Other e rids +.A Number,of living units: _LL Number rooms Water table depth Character of soil to a depth of 3 feet: ' t SEPTIC TANK q7ype/Mfg - Capacity No. Compartments PKC. TREATMENT PLT. / Method of Disposal r Distance to nearest: Well� Foundations Property Line Cv 1 d Totallen'th/size 6 r r" LEACHING LINE Pt No. & Length of lines ' f g I FILTER BED ❑ Distance to nearest: Well r Foundation , Pniji rty Line `s SEEPAGE PITS ir.�Depth y l Size+ lumber� -� ! SUMPS Ll `Distance to nearest: Well Foundation /Property Line �f " �eLZ 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 taws#and rules and regulations of the San Joaquin Local Health District. t 4 I 3 IHome owner or licensed agent's signature certifies the followings"I certify t6 ih�:xhrte perrr/c of the work for which this permit is issued, I shall not 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 1111 certifies the following: "I certify that in the performance of the work for which this permitis iss�, I shall employ persons subject to workman's compensa- tion laws of California." The applic wt must call for II required inspections. ComQlete'drawing on reverse side. MtsTM�{ "ici1 ) Title: r Date: k Signed X�. � i�T� s FOR DEPART-MENT{USE ONLY j U wf, r Application Accepted byDate ^� Area 2 :1 or Grout Inspection by ate Final Inspection by` Date U e Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Ment ca' 823 71b4 J L'" 1 Tracy 835-6385' r Applicant - Return all copies to: Enviranm`nt ealth Permit) ervic s 1601 E. Hazelto ve. Box 2009, tk., CA 95201 FEE AMOUNT DUE `]r AMOUNT REMITTED SN RECEIVED BY DATE PERMITNO. INFO ny ..EH 13-24 IREV.I r EK 14-26 I