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x ter'. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.,.STOCKTON, CA Telephone (209)'466-6781 PERMIT EXPIRES 1 YEAR FROM DATEISSUED {U (Complete in Triplicate) 3 r °' application is Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of theSanJoaquin Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. Tins app made in compliance with San Jo q Local Health District.. ,A City ' Lot Size s G PM Job Address a Phone �bi �! , � .y � e Address Owner's Name _ License NNo. =d� Phone ')JZ4 Address _ —_w __ Contractor _ ---- – WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF WELL/PUMP: ''I NEW WELL ❑ OTHER ❑ F SYSTEM REPAIR ❑ p0M INSTALLATION ❑ `� DISPOSAL FLD- PROP. LINE n , SEWER LINES —� OTHER WELL PITS/SUMPS N DISTANCE TO NEAREST: SEPTIC TANK 5 AGRICULTURE WELL FOUNDATION i TYPE OF WELL PROBLEM AREA i' CONSTRUCTION SPECIFICATIONS , INTENDED USE Dia. of Well Casing ❑ Open Bottom ©;Manteca- Dia. of Well Excavation Specifications D Industrial ; + Type of Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of G#out l ❑ Other ❑•iDelta Depth of Grout Seal ❑ Public ( r Surface Seal Installed by ❑ irrigation f i—J�PProx. Depth ❑.•l astern, .,, j t, y l H P State Work Done Repair Work Done r Q Type:,of Pump i # Sealing Material (top 50'1 Well Destruction ❑ Well Diameter — f Depth _ �F.iller,.Materiai (Below 50') — � available within 200 feet.) ) TYPE OF SEPTiC WORK: NEW INSTALLATION ❑i REPAIRIADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is I Commercial�I Other'�� Installation will serve: Residence L S d Number of living units: Number of bedrooms r Water table depth k Character of soil-to a depth of 3 f et: Capacity No. Compartments SEPTIC TANK lye ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ Foundation Property Line Owl, to nearest: Well I 1 Total length/size LEACHING LINE d No. & Length of lines Pro a Line ❑ Distance to nearest: Well ---FoundationT_� P rtY FILTER BED i j _ Size Number SEEPAGE PITS ❑ Depth Foundation .�Q-0 Property Line SUMPS ❑ Distance to nearest: Well i ❑ 1 I hereby certify that I have prepared this application and that the work will county ordinances, state laws, and DISPOSAL PONDS kwiil be done in accordance with San Joaqui rules and regulations of the San Joaquin Local Health District., Home owner or licensed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I signature shall not employ any Person in such manner as to_become subject,to workman's compensation laws of California."Co`otractto�nsisubject to orkmansub-contract�scompensa certifies the following:"I certify that-in the performancring or e of the work for which this permit is issued,I shall employ P tion laws of California." t ? ' The applica must tail for all required inspections:-Com olete drawing on reverse side. N �^ i�,Date: `' � Title: � � i4 Signed _ .F- FOR DEPART ENT USE ONLY � /1 y s Data .- Application Accepted by 1 Date Final Inspection by -- Date - Pit or Grout Inspection by Ad itional Comments: '' -Stk 466-6781 a Lodi 369 36?1 ❑ Manteca 823-7104 ❑ Tracy 835 6385 ! Ap licant Return all copies to:,Fnvironmental Health permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk:, CA 95201 iRECEIVED BY" DATE PERMIT NO. FEE AMOUNT DUE =AMOUNTED (NFD s s� - + EH 13-24(REV.I A 57 L� ''� i•�� , EH 14.25