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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL � r { *° � �•`� i 1601 E. HAZELTON ON HEALTH DISTRICT AVI:., STOCKTON, CA Telephone (2og) 4W_ PERMIT EXPiRES,7.VE gR F 6782 ROM DATE ISSUED ' Application is { � t made in compliance wrth San de to the San la um Local H (Complete in Triplicate) q Local Health District. : eaith District fora .. ,ty Ordinance No.543 for Permit to construct and/ori "t _ sewage or No. Icon for welf/Pumt and/or mall the work herein descri Job Address ( P and the Rules and R TFes application is Regulations of the San J uin (` oaq Owner's Name i Cm' - Lot Size arZ_ Address a `-PM Contractor _ 3 TYPE OF WELL/Pr - / Phone MP: rens NEW W PUMP INSTAL WELL ❑ WELL REP ease fYo� DISTANCE TO INSTALLATION ❑ REPLACE ❑ DESTRUCTION ❑ Phone v! NEAREST; SEPTICTANK SYSTEM REPAIR ❑ FOUNDATION � SEINER LiNES OTHER ❑ INTENDED 115E AGRICULTURE WELL DISPOSAL FLD. TYPE OF WELL — OTHER WELL ~ PROP. LINE industrial PROBLEM CONSTRUCTION �~ PITS/SUMPS _ ❑ Domestic/Private Open Bottom SPECIFICATIONS ❑ Gravel Pack CONSTRUCTION Dia, of Well Excavation ❑ Public ❑ Tracy Dia, of Well Casing ❑ irrigation ❑ Other Type of Casing � ❑ Delta Depth of Grout Seai Repair Work Done —APProx:"Depth ❑ Eastern Specifications ❑ Type of Pump Surface Seal installType of Grout H.P. ed by W611 Destruction ❑ Well Diameter 7 _ �l. Seaiing Material (to State WvHc Done I Depth t p r�p�j - - f TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ Filler Material(B I l w 50'i REPAIR/A DE57RUCTION ❑ (No septic system Installation will serve; Residence Commercial available within Permitted if public sewer is Number of living units: _ Other 200 feet.) Character of soil to a depth of 3 feet of bedrooms SEPTIC TANK a• Type/Mfg L PKG. TREATMENT PLT. Capaci Water table depth No.ty - Compartments Distance to nearest; Well Method of Disposal --� LEACHING LINE Foundation�� Property Line ❑ No. & Length of lines"". - T- FILTER BED ElDistance to-nearest: P Well Total length/size ,Foundation SEEPAGE PITS ` Property Line _ ❑ Depth SUMPS DISPOSAL PONDS Size �. '❑ Distance to nearest: Wel Number ❑ Foundation 1 hereby certify that i have prepared this application and that the work will bed —`Property Line rules and regulations of the San Joaquin Local Health District. ~ Home owner l licensed agent's signature certifies the following: do in accordance with San Joaquin county ordinances, state laws, and eMOOY anY Person in such manner as to become subject to workman's compensation laws of California."Contractors hirin or "i certify that in the Performance of the work for which this permit is issued, 1 shall not certifies the following:"1 certify that in the performance of the work forwhich this tion laws of California." permit is issued,I shall employ g sub a workman's signature The applicant must c fflr Ire inspections. Co tete drawing P Y Persons subject to workman's compensa- r • g verse side. # Signed Title: r Date: FORD ARTMFNT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by f k, Date Finallnspecti by Additional Comments: Date ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 applicant- Return all copies to: Environmental Tracy 835-6385 Health Permit/Services 1601 E.❑Hazelton,Ave P-0. Box 2009 Stk., CA 95201 FEE AMOUNT DUE INFO AMOUNT REMITTED CK RECEIVED SY CASH 1EV.I/as) DATE 7DPERMIT"NO. , pO ,,. x