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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEILTON AVE., STOCKTON, CA Telephone (209) 466-6781 ,PERMIT EXPIRES J'YEAR FROM DATE ISSUED (Complete in Triplicate) application is un Ordinance No.548 for sewage or No. 1662 for welllpump and the Rules and Regulations of the San Joaquin Application is he+eby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described. This made in compliance with San'Joaquin-Co ty �` � � Local Health District. Lot Size P aP 170,31 t� City. Job Address i q cL Phone Address d� Owner's Name 4 —License Nolr`+'�!�Phone Address!'.,�"�- DESTRUCTION ❑ \ Contractor WELL REPLACEMENT ❑ TYPE OF ELL/PUMP: NEW WELL LJOTHER ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISPOSAL FLD. LINE DISTANCE �. SEWER LINES PITS/SUMPS NEAREST: SEPTIC TANK AGRICULTURE WELL OT >t TION SPECIFICATIONS INTENDED USE TYPE OF WELL PROBLEM AREA Dia, of Well Casing Dia. of Well Excava i t ❑ Industrial ❑ Open Bottom ❑ Ma 1` ecifications 0 Tracy Type of Casing ❑ Domestic/Private Ll Gravel Pack I Depth of Grout Seal Type a ' ❑ Other f 1 Delta { Public Surface Seal Installed by Q `-Approx. Depth t I Eastern State Work Done— JV I Irrigation H.P. � - _ �-- Repair Work D L7 Type of Pump r Sealing Material (top 50'1 W ruction ❑ Well Diameter Filler Material (Below 50'1 Depth —�—~ vailable within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION l HEPAIR/ADDITION l 1 DESTRUCTION'S(No septic system permitted if public sewer +s C Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Capacity No. Compartments \ i SEPTIC TANK ❑ Type/Mfg Method of Disposal 1 PKG. TREATMENT PLT. ❑ Foundation Property Line I Distance to nearest: Well ,I Total length/size v LEACHING LINE ❑ No. & Length of lines Foundation Property Lines - ^ FILTER SED ❑ Distance to nearest: Well SEEPAGE PITS C I Depth Size Number SUMPS El Distance.to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ C nd that the work will he dans in accordance with San.Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application a rules and regulations of the San Joaquin Local Health Di'strict.g" artify for that in the Home owner or licensed agent's signature certifies subject flto wing: "I n's compensation laws of Califo�niahe Contractor's Nr's1huing or sub-contracting signatu�e employ any person in such manner as to becomarsons subject to workman's compensa- certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ p tion laws of California." The applicant ust call for all required inspect Complete drawing on reverse side. pate: Title: Signed FOR DEPARTMENT USE ONLY Date Area l Application Accepted by Data ` Dat© Final Inspection by Pit or Grout Inspection by _ . Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 L3 Tracy $35-6385 nvironmental Health Permit/Services 1641 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Applicant - Return all copies to: E CK RECEIVED BY DATE PERMIT tJO. IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH a.EH 13-24#REV.1 n 5f � EH 14-28