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PLICATION FOR PERMIT 7 r � �f tJ o o.j AP ff.pp'' `/� Y } S�T� �r�`P pI S!f{. t-ba� SAN JOAQUIN LOCAL HEALTH DISTRICT J STOCKTON, CA 1601 E. HAZELTON AVE., Telephone (209) 466-6781 t PERMIT EXPIRES 'YEAR FROM01ISSUED #: (Complete in Triplicate) ucation is F ermit to construct and/or Insat��the Rules and rRegulationds of the San Joaquin Ordinance No.549 for sewage or No. 1862 for well/Pump Application is hereby made to the San Joaquin Local Health District fora p made in compliance with San Joaquin'ouniy le-1-41M __ Local Health District. City Lot Size Job Address/ �� Phone U j) � License Address DL Owner's Name —Phone No.�--- r Address �% DESTRUCTION O r ContractoNEW WELL WELL REPLACEMENT ® OTHER ❑ { TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ PRO?. LINE l9a k pUp,{p INSTALLATION 5k <90 1 DISPOSAL FLD• PITSISUMPS 3rd SEWER LINES OTHER.WELL— r DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELLn� r� FOUNDATION `— PR08t��M CONSTRUCTION SPECIFICATIONS Dia. of Well Casing TYPE OF WELL Dia. of Well Excavation + Specifications' + INTENDED USE Q Manteca " 1. ❑ industrial, Open Bottom Type of Casing ❑ Tracy ,�p 1 Type of Grout Gravel-Pack Depth of Grout Seat - +} Domestic/•Private---� ) i-i Delta >� Cl other Y F Surface Seal Installed by i I Public t I Eastern AppruX.m Depth Stage Work one— 1 ! I Irrigation -� H.P. Wr�►�•'• m T Repair Work Done ❑ ,Type of Pump r (o Sealing Material (tap 50'1 Well Destruction II* Well Diameter �— Filter Material (Below 50'1 ermined if public sewer is I Depth s ,�r? I F available with in,200.feet.f + NEW INSTALLATION l 1 ADDITION l 1 DESTRUCTION i ! lNo septic systetn.p TYPE OF SEPTIC WORK - Commercial -Other Installation will serve: Residence >.�, k.. Water table depth Number of living units: ,.Number of bedrooms��— I -- No. Compartments Character of soil to a depth of 3 feet: Capacity— SEPTIC TANK" ❑ Type/Mfg Method of Disposal r I PKG. TREATMENT PLT. O t Foundation =�,Property Line 'Well ��— � Distance to nearest: _ :.: . - I i l Total lengthlsize LEACHING LINE ❑ No. & Length of lines Property Line -- I � Well Foundation�— FILTER BED ❑� Distance to nearest: Number I DeptSize SEEPAGE PITS h Foundation Property Line 1--- I SUMPS Cl Distance to nearest: , Well , state laws, an DISPOSAL PONDS Q` '# l hereby certify that I have prepared this apPlicaµealand that th Districtne work will be done in accordance with he work for(which this permit isunty sssued, I shall not rules and regulations of the San Joaquin Local I certify that in the performance of I Home owner or licensed agent's signature certifies the following: " Y signature performance of the work for which this permit is issued, I shall employ Persons subject to workman's compensa emptoy.any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting 9 certifies the following:"I certify that in the Pe I tion laws of California." r The applicant u t call or all.requir d 7�� isComplete drawing on reverse side. Date: Cs (J le: Signed X i FOR DEPARTMENT USE ONLY te pa r r' / Ar I ApplicaU Accepted by / C Ec/� Date f Date-' F l?lspection by Pit inspection b r r u G 835-6385 Additional Comments: [1 Manteca 1323 71 ❑ Tracy ❑ Stk 466-6781 ❑ Lodi 369-3621 5201 Applicant- Return all copies to: Envi� nt��'Perm��3�y1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9 � PERMIT'No, CK RECEIVED BY DATE EAMOUNT REMITTED? CASH[![ja � � Z +".EH 13.24'REV.i i n 51 —7/1 &,-j e 7 K—W EH U-29