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APPLICATION 'FORPERMIT HEALTH DISTRICT SAN JOA LOCAL E., .STOCKTON, CA 1601 E. HAZEL,ON AV Telephone (209) 466.6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED `' (Complete in T(plicate) bed TW application is 4 x or and the Rules and Regulations of the San Joaquin wa a or No. 1862 for weNlp p e San.!�aquin Local Health District for �r agpermit to construct and/or install the work herein descn Application is hereby made to the Ordinance No.` f G^ made in compliance with San Joaqul County PM Local Health District. ; 3� . City Lot Size 3 III. ..� s w i Job Address d S Phone l _S �jno� Address �� -a �Pi "�S'j� Phone 'j Owner's Name , License No. i �N��EWWE ddressDESTRUCTION ❑Contractor LL ❑ WELL REPLACEMENT ❑ OTHER ❑ TYPE OF WELLIPUMP: PUSYSTEM REPAIR d PROP. LINE MP INSTALLATION �� DISPOSAL FLD.— PITSISUMPS w ^ SEWER LINES �� OTHER WELL_� j DISTANCE TO NEAREST: SEPTIC TANK p,GRICULTURE WELL FOUNDATION Dia. of Well Casing PROBL�AREA CONSTRUCTION SPECIFICATIONS TYPE OF WELL Dia. of Well Excavation Specifications l It INTENDED USE ❑ Open Bottom [3 Manteca ❑ industrial ❑Tracy Type of Casing ' Type of Grout I ❑ Gravel Packw .. ;_ Depth of Grout Seal ❑ DomesticlPrivate—_ ❑ elta ❑ Other Surface Seal Installed by k ❑ Public �pprox. Depth ❑ Eastern State Work Done- ❑ Irrigation H.P. a. N =�.., - Material (top 50'1 r Repair Work Done ❑ Type of Pump- .._,.__.,r Sealing I Well Destruction ❑ ,Well Diameter Filler Material (Below 501) ermitted if public sewer is Depth A DESTRUCTION ❑ (No septic system p REPAIRlADDITIDN ❑ available within 200 feet.} -^ TYPE OF SEPTIC WORK: NEW INSTALLATION%a- WORK: s f v ICommercial- Installation will serve: Residence 1 !Number of bedrooms Water table depth Number of living units: -;'Num , artments No.-Comp Character of soil to a depth of 3 feet, L -� CapacitY� Method of Disposal Character ❑ Typ'/Mfg f SEPTIC TANK. �. Property Line j PKG.TREATMENT PLT. ❑ Well�� Foundation Distance to nearest: �6 ' Total lengd o size r / ❑ No. &Length of lines property Line- � t I LEACHING LINE r Well ER SED 1 Foundation I FILT ❑ 'Distance to nearest: . > Number i �, Size Property Line r. I E Depth Foundation�- l SEEPAGE PITS >= Weli�. 1 SUMPS ❑ Distance to nearest state laves, and DISPOSAL PONDS ❑ lication and that the work will be done in accords€ce with San Joaquin county or trrrai t is issued, L shall not y, tch this pe I hereby certify that l have prepared this app that in the performance of the work for wh signature rules and regulations of the San Joaquin Local Health District. I certify b�contracti Home owner or licensed agent's signature certifies the following: '" nsation laws-of_CaV'rfornia." Contractosori Isubj ct to workman's pensa to any Pe performance of the work for which this permit is issued,l shah employ Pe " employ person in such manner as to become subject to wo`rkikfosvAiich I certify that in the pe t 1 certi ies the following:" tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. pate. Title: G 1 Signed Q FOR.DEPARTMENT USE ONLY 7 Area Date !r Date Application Accepted by Final Inspection by .~ .. Date Pit or Grout Inspection by I e I 7104 ❑Tracy^83r6� r Additional Comments: ❑ Lodi 36g 3621 ❑ Manteca 823 1 ❑ Stk 466-6781 Applicant- Return all copies to: environmental Health Permit/services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CK RECEIVED BY DATE PERMIT'NO. t e FEEAMOUNT DUE AMOUNT fiEMITTED CASH INFO +EH 13.,24 iREV.1/69) - lw fi• '-EH 14.28_ ,----»•- - -