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APPLICATION FOR PERMIT „ ,, ,....—�, SAN JOAQUIN LOCAL HEALTH DIStRTICT 1601 E. HAZEL T ON AVE:, STOCKTON, CA f Telephone (209) 466-6781 y PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) lication is OidinancetiNo.549 for sewage or No:1862 for well/pump and the Rules and Regulations of the San Joaquin Application is hereby-made-to.the San loanuin Local Health District fora per to construct and/or install the wok herein described. This app made in compliance with.San Joaquin Co N Local Health District. PM 7 WC City Lot Size Job Address r Phone Address Owner's Name i C3=y/�•J�'�� r ` Phone cense No. Contractor's Name WELL REPLACEMENT ❑ DESTRUCTION ❑ ` TYPE OF WELL/PUMP' NEW WELL ❑ SYSTEMOTHER ❑ REPAIR ❑ PROP. LINE PUMP INSTALI.AT10 DISPOSAL FLD. SEWER LINES PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK �� AGRICULTURE WELL OTHER WELL FOUNDATION F INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing dQ ❑ Open Bottom 0 Manteca Dia. of Well Excavation p ❑ Industrial Specifications 1 q ❑ Gravel Pack ❑ Tracy Type of Casing _ i. Type of Grout �] ❑ Domestic/Private ❑ Delta Depth of"Grout Seal ` ❑ Public ❑ Other t Depth ❑ Eastern Surface Seal Installed by [I Irrigation Irrigation H.P. ='Stale Work Done Repair Work Done ❑ Type of Pump Sealing Material,(top 50'1 {J:.• k Well Destruction r_1 Well Diameter Filler Material (Below 501 Depth I TYPE OF SEPTIC WOR K: NEW WSTALLATION ❑ REPAIR/ADD I LION L) DESTRUCTION ❑ aNailable�with ne200 feetit�ed if public sewer is I Installation will serve: Residence i Commercial_. Other�— Number of living units: Number of bedrooms Water table depth Q. Character of soil to a depth of 3 feet: Capacity—�-�� No. Compartments SEPTIC TANK [ITypelMfg � Method of Disposal Y PKG. TREATMENT PLT. _ _ ��" " z t Foundation'r�� Property Line € pistance'to nearest: Well v w f t �� Totallengtlilsize l LEACHING LINE L3 No. & Length of lines W- ~� Property tine *' Foundation FILTER BED �• ❑ "Distance to nearest: well r Number SEEPAGE PITS ❑ Depth Size Property Line � SUMPS El Distance to nearest: Well Foundation # DISPOSAL PONDS ❑ Thereby 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 District. permit is issued,work for I Home owner person rlicensed agent's Baas not urb comes th ectt to workman's kman'sfollovVing: 11 rtcompensation lify that in the aws of California."rmance Contract r'slhir hiring or sub-contracting l signature employ y t certifies the following:"I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compen sa- tion laws of California." . The applicant must call for all requir inspections. Campfete drawing on reverse side. Date,. Signed Title: Date Signed R DEPARTMENT USE ONLY �A,I "I Date Application Accepted by Appl p o J Pit or Grout Inspection by Data— - Final Inspection by Date t Additional Comments: ❑ Stk 466-6781 ❑ Lodi 365-3621 ❑ Manteca it/Services ❑ Tracy 835-6385Ave., P. I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton ., P.O. Box 2009, Stk., CA 95201 RECEIVED BY ;DATE PERMIT`'h10. r FEE AMOUNEDUE J!!!!ECASH INFO • + EH 13-241REV.10/831 S, ` cu tiNt