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_ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaq uin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpu`p and the Rules and Regulations of the San Joaquin Local Health District. 1 City Lot Size PM Job Address Phone Address Owner's Name f ' License No.�Phone Address Contractor WELL REPLACEMENT EDDESTRUCTION ❑ TYPE OF WELL/PUMP: NEW WELL ❑ OTHER a Ill PUMP INSTALLATION D SYSTEM REPAIR Q DISPOSAL FLD. PROP. LINE SEWER LAVES —�� DISTANCE TO NEAREST: SEPTIC TANK –.--- AGRICULTURE WELL OTHER WELL PITS/SUMPS FOUNDATION ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of WeA'Casing Dia. of Well Excavation [2 industrial ❑ Open Bottom C7 Manteca p r Specifications ❑ Tracy Type of Casing [IDomestic/Private ❑ Gravel Pack - 1 Type of Grout Ll Other ❑ Delta Depth of Grout Seal n Public t . . Surface Seal Installed by T I I Irrigation �-.Appro Depth I ! Eastern State Work Done , H.P. } 4r Repair Work Done ❑ Type of Pump , On Well Destruction ❑ Well Diameter �--- Baling Material (top 50'1 i Depth I Filler Material (Below 50') permitted if public sewer is available within 200 feet.) _ ( TYPE OF SEPTIC Wo NEW INSALLAT ON t. REPAIRIADDITION l 1 D> STRUCTION-l.l (No septicstem� Commercial 1-- l installation will serve: Residence� /� f Number of living units: Number of bedrooms T Water table depth Character of soil to a depth of 3 feet: o:x –"mp-a- n Capacity_ NCompartments Mf ❑ Type/ g ? SEPTIC TANK � , may.. Method�of Disposal PKG, TREATMENT PLT. ❑ ` r r��r ' } Foundation Property Line_ Distance to nearest: Well ��.�.- - I =T tal length/size � Length of lines LEACHING LINE No. & Lec �. r _ Foundation _ Property Line FILTER BED 0 Distance to nearest: Well o I t i 1 '3S :1_ize /r Number SEEPAGE PITS l i DepthProperty Line f .t +� Foundation { SUMPS CI Distance to nearest:, Well DISPOSAL PONDS ❑ r k will be done in accordance with San Joaquin county ordinances, 'st I hereby certify that l have prepared this application and that the worare laws, an { rules and regulations of the San Joaquin Local Health ptrict. work for sh Home owner or licensed signature certifies the to become subject to workman's Rcompensation Iity that,in the la soof California."Contractor's v 'hiri gI or sub-contracting ermit is issu d, lsignature employ any person in suchp persons subject to workman's compensa certifies the following: "I certify that in the performance of the work far wN#ich this ermit is issued, I shall employ F tion laws of California." The app ca!Accepted st I for all require spec ns; C plate drawing an averse side. 3 l I pate: Title: Signed X FO PARTMENT USE ONLY `Q� Date �-ff / Area r 5 i Application by Date Pit or Grout Inspection by Date Final Inspection by i i Additional Comments: Trac ❑ 5tk 466-67$1 ❑.Lodi_3693621__ _ ❑ Manteca-.B23-7104____❑.. - Y" . . Applicant - Return all copies di Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 55201 DATE PERMIT�.NO, FEE AMOUNT:DUE AMOUNT REMITTED A RECEIVED BY y\ p INFO �'�� Q 9 135 } v0 `P ♦.EH13-241at�l.i/H51 0 �� -70. EH 54-2e -