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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE: ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r 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 compliance with San Joaquin County Ordinanoe No.549 for.sewage or No. 1862 for weal/pump and the Rules and Regulations of":_San Joaquin Local Health District., " It) �I�•�' �f Job Address City J ! !J1'� Lot Size_._.._ PM f. Owner's Name L �Ca ddress / u/ �1 ) ,.f!1/GCC1 j 1 'l1, Phone Contractor _ ._Address L censee N'oo..7_— — --Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION G PUMP INSTALLATION 7 SYSTEM REPAIR C OTHER [:; DISTANCE TO NEAREST: SEPTIC TANKSEWgR LINES DISPOSAL FLD._„__ PROP. LINE FOUNDATION AGRICULTURE WELL _ OTHER WELL — PiTS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIF1CATfONS Industrial t✓ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weft Casing C Domestic;Private 0 Gravel Pack Tracy Type of Casing—._. Specifications O Public n Other ° Delta Depth of Grout Sea! Type of Grout... _........ _ 7 Irrigation _.Approx. Depth 0 Eastern Surface Seal Installed by Repair Work Dona D Type of Pump N.P. State Work Done Well Destruction C Well Diameter __— Sealing Material Itop 501 ' Depth------... Filler Material(Below 50') ....-.--..............._._-_. t TYPE OF SEPTIC WORK., NEW INSTALLATION t7 REPAIR/ADDITION DESTRUCTION l 1 (No septic system permitted if public sewer is ! - ,. ^ ave able wit in 200 feet:! _ installation will serve: Residence-......_ Commercial___ Others Number of living units:____ Number of bedrooms Character of sod to a depth of 3 feet: - W er table depth SEPTIC TANK LJ Types Mfg';' Capacity No. Compartments 1 PKG. TREATMENT PLT, ; Method of Disposal 4 Distance to nearest: Wdt_.. _ Foundation'__--. ...= Property Une ......-. _.... _ . �,-IEACHING LINE :l No. & Length o1 fines � �Total length/size_. 01 FILTER BED U Distance to nearest; Well Foundation jf7�- Property Line r _. SEEPAGE PITS r: Depth__._. _.Size Number—_._.... _ Distance` to,nearest: Well Foundation . Pr” SUMPS :.; oparty Line DISPOSAL PONDS Fal t hereby canify that i*have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws, and y- rules and regulations of the San Joaquin Local Health District. Horne owner or licensed agent's signature certifies the fohowing: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California-"Contractors hiring or sub-contracting signature certifies the following: "i certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant II f a �'red ins tions.'Complete drawing on reverse side. .+ t a Signed X _ -:._ .. •„�id��+�`rs�,-....--•�.... 7itie:—...._ �-'1e=�e1,Y�... _. Date: ...�•,.Lslrr}._t�— DEPARTMENT EPARTMENT USE ONLY .: Jif Application Accepted b`y ;yi` L� _.:� _..._.. pate_. _��"� Arm x Pit or Grout Inspection-by iryFinal Inspection b Oates" _.— Additionai Comments: C Stk 466.5781 C Lodi 369 3621. . �4• Manteca 823.7104 L7 Tracy 635-639- Return all copies to: Environmaa461- e h Permit/Services 1501 E. Hazelton Ave., P.O_ Box 2009, Sk., CA 95201 FEE «AMOUNT DUE . AMOUNT REMITTED 0 `RECEIVED BY DA'ft PERMIT N0. INFO