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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 F. HAZEILTON AVE., STOCKTON, CA l Telephone 12091 466-6781 x I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' (Complete in Triplicate} ' .,L. n Couri Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Application is hereby made to the San Joagrin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin T^ Local Health district. ! ' city 7Zy�� Lot�S�zei PM 004 w . .yy Gt Job Address - { � Phone •y Owner's Name �r� l Address wpb License Phone Contractor I/ Zqr• Address WELL REPLACEMENT ❑ DESTRUCTION CDy TYPE OF WELL/PUMP" � : ' NEW WELL ❑ OTHER ❑ SYSTEM REPAIR ElpROp LINE ' -• asp_ PUMP VNSTALLATION ❑ DISPOSAL FLD. .�..�•�-- �^"° '" '"y - SEWER LINES ��-- DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS �— FOUNDATION AGRICULTURE WELL INTENDED USE TYPE OF WELL PROBL� EM AREA CONSTRUCTION SPECIFICAT10N5 Dia. of Well Casing Dia. of Well Excavation p Industrial ❑ Open Bottom 1 ❑ Manteca Y Specifications ❑ Domestic/Private ❑ Gravel Pa Type of Casing I ❑ Tracy Type of Grout ❑ Other I[ ' - ❑ Delta Depth of Grout Seal , ❑ Public Surface Seal Installed by ❑ Irrigation �APProz.`Depth [11 Eastern State Work Done I H.P. o Repair Work Done 11 Type of Pump Sealing Material )top 50'} Well Destruction [I Well Diameter Filler Material (Below 501 Depth ' available within 200 feet.) �. TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ iNo septic system permitted if public sewer is _ Installation will serve: �F esidence �Commercial Other l— , Number of living units:' Number;of bedrooms Water table depth t ' Character of soil to a depth of 3 feet:Type/Mfg '� �fQ�j No. Compartments ig'. 4 Capacity�— SEPTIC TANK ; Method of Disposal a . j f PKG. TREATMENT PLT. ❑ 1 Foundation Property Linee— P Distance to nearest: Wellld� ,! s Total lengthlsize I LEACHING LINE �F No. & Length of dines / v.prop�Tty Line—L�p C t *" I Distance to nearest: Well� Foundation .. a FILTER BED 1 r i y � � " � Size Number SEEPAGE PITS ❑ Depth' Property Line ! _ ❑ Distance 1 to nearest: Well Foundation�� 1 SUMPS f •-q DISPOSAL PONDS ❑ ff ll I hereby certify that I have prepared this application and that the work will be done•in accordance With San'Joaquin county ordinances,-state laws; an 3 rules and regulations of the San Joaquin Local Health District. that in the performance of the work for Which this permit is issued, 4 shall not Home owner or licensed agent's sigriature certifies the following: 1 certify employ any person in such manner as to become subject to workman's compensation Paws of California." Contractor's 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� r + tion laws of California: j The applicant must tail for all required inspections. Complete de. ctCmlete drawing oreverse si 8� w Date: f Title: Signed r L FOR DEPARTMENT USE ONLY f Date �- l� S Area l� t i Application Accep by /p-�c k Date Date U Final Inspection Pit or Grout Inspe on µ s .w 0 Additional Comments: ❑ Manteca 823-7104 ED Tracy 835-Mi ❑ Stk 466-6781 ❑ Lodi 369-3621 i Applicant Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK RECEIVED BY DATE PERMIT NO. 1 PEE AMOUNT DUE AMOUNT REMITTED CASH �7 I INFO NO +r r (> 1/ 0 +EH 53-24 (REV. /65� 1�•D " EH W26