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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466,8781 APERMIT EXPIRES 1 YEAR FROM HATE ISSUED } ._....�..____a...._._..__-(Complete in Triplicate) Application is hereby made to the.San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compiaance with San Jostluin County Ordinance Nn.549 tar sewage or No. 1862 for well/pump and the Ruies and Regulations of the San Joaquin Local Health District, Job Address �_'�'.i..��1 L��'�..s„a 1`i.._� City fyTIS0 t_ �i.3t i PM Ow+aei s Name Address Phone Contractor � ,.,...Atldress... ._” -�. �.. _SdL��i icense Na.`&_J..a.fN2a PII_ TYPE OF WELL/PUMP! NEW WELL Cl WELL REPLACEMENT 0 DESTRUCTION C PUMP INSTALLATION L"7. SYSTEM REPAIR D OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. _ PROP. LINE . FOUNDATION AGRICULTURE WELL .................__._— OTHER WELL PITSISUMPS ._.,-.. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial Open Bottom Ll Manteca Dia.of Well Excavation Dia.of Weil Casing Cl Domasva/Private D Gravel Pack �n Tracy Type of Casing—, Specifica'tians I"'l Public El Other „r-( Delta Depth of Grout Seal Type of Grout . I I irrigation ___,_..Approx. Depth] 1 [ Eastern Surface Seat Installed by Repan Work Done L] Type of Pump _.._ H.f. State Work Done ____.......... ._..... Well Destruction 'D We"Diameter Sealing Material [top 501 Depth" �__._.....! ,.,._Friler.Matena[,jBeIo y_50'i TYPE OF SEPTIC WORK: .NEVI!INSTALLATION I.': A€PAIR/AD04TiON RUCTION I i INo staptic system permitted if public sewer is available within 200 feet.) Installation will serve' Resiiddence ommetrial`-+ '-Other L.:' ". ._ bedrooms; �.__..._ Number of saving units: ._ _ s _,/Number of bedroom_-" _ Character of soil to a depth,of 3 feet: ___..._ Water table depth --- __ SEPTIC TANK =- gpetfvlfg _ 3..._._._..... Capacity__Zk:j0_0, No, Compartments,,.. PKG. TREATMENT PLT,L ' Method of Disposal Distance to near: Well, Fausadatiar ._�_ Pt aparty Line �1 LEACHING LINE ;a 8 Length Of __._.._ l.r--~�� t TOW fgtitts)ztt FILTER 8£D r RC1 Distance to fieetabat Well _ µ --Rovndation Property � r .� } Size SEEPAGE PITS 1 1 Depth> P �._._.._.. _ .� Number -.•, 1 SUMPS ; 0' Distance to nearest: Welt. Foundation�....__ } Property}, 11" DISPOSAL PONDS n' fi.. i y i ,_.rll At -1 hereby candy that t have prepared this application and that the work will he done in sctordance with San oaq J uin county ordinances, state Taws, and ' rules and regulations of the San Jowiuin Local Hea" Di'§trict, 1 Homeowner or licensed agent's signature certifies the following. "l certify that in the periormanca 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[avers of Californis."Contractor's hiring at sub-contracting signature ca the following:"I certify that in the performance of the work for which this permit ii issated,I shad employ persons subject to workman's compensa- toon laws Californi III The applic nt c for l rued s cti n drawing on r sa side. c- �S�ned .. i DEPARTMENT USE ONLY Application Accepted by ._._ ..___. ! Date _. � � L � Area Pit or Grout Inspection by _ Data __ Final Inspection by, Data !t+ Additional Comments: L; Stk 466-6781 0 Lodi 369.3621 © Manteca 823-71134 0 Tracy 8366385 - Applicant- Return all copies to: Environmental Health PermitlServicas 1601 E. Hazelton Ave_ P.O. Bort 200, Stk.,CA 95MI FEE INFO AMOUNT 0 E AM6UNT AEMiTreo 4 CASH lr r AECEIVEt7'8Y OATS � ` PERMIT NO. ."EN 13-24 1REV.e/s�5: + ._...._.. EN 14.28 /✓1•. y