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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San,oaquin 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District, C� 4 City Lot Size PM Job Address / f./� 23vs ' Phone `7co J Address 3 co r Owner's Name "e � Contractor Address License No._ Phone NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O j TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ OTHER ❑ PUMP INSTALLATION ❑ SEWER LINES DISPOSAL FLO. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS AGRICULTURE WELL OTHER WELL FOUNDATION -�.�— i NSTRUCTION SPECIFICATIONS TYPE OF WELL PROBLEM AREA CO INTENDED USE Dia. of Weil Casing ❑ Industrial K Open Bottom ❑ Manteca Dia. of Well Excavation Specifications i T e of Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type Type of Grout 'l ❑ Other F1 Delta Depth of Grout Seal i'1 Public Surface Seal Installed by Irrigation ___Approx. Depth l l Eastern i H.P, State Work Done �. Repair Work Done L2m Type of Pup --�— Sealing Material Itop 50'f I W�Destruction Qtr Well Diameter Depth sI 00 Filler Material (Below 501 21 " TYPE OF SEPTIC WORK: NEW INSTALLATION i7 REPAIRIADDITIDN 4 I DESTRUCTIO i I availableNo fwit hine200 feet.) it public sewer is Installation will serve: Residence i 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. ❑' Property Line Distance to nearest: Well Foundation 1 4Total length/size LEACHING LINE No. & Length of lines ❑ Distance Well Foundation property Line e to nearest: � FILTER BEP I l Size Number SEEPAGE PITS I I Depth.I, SUMPS L-1Distanceto nearest: Well Foundation Property Line 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. Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature I 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 compensa- tion laws of California." l The appticust 1l for all required i spections. Complete drawing an reverse an S Date: Title: S Signed X k FOR DEPARTMENT USE ONLY l Date Area Application Accepted by Pit or Grout lnspectio Date Final Inspection D. Additional Comments 5-6385 ❑ 5tk 456-6781 ❑ Lodi 369-3621 ❑-Manteca 823 7104 ❑ racy Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA 95201 r� CK RECEIVED BY DATE PERMIT-NO.FEE AMOUNT DUE AMOUNT REMITTED CASH INFO " + EH 1124 iREV.t/n 5) # . EH 14.26 s