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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE.. STOCKTON. CA Telephone ROW 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) i [tion is heieby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is 1 a compliance with San Joaquin County Ordinance No.549 for sewage or Na.1862 for wall/pump and the Rules and Regulations of the San Joaquin iealth District. r City Lot SizedeAA4PM i s Name' Address Phone tctAP Address w License No Z Phone. by+ �U OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ \' INCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE-- FOUNDATION INE_FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS TENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS {ustrial ❑ Open Bottom ❑ Manteca Dia_ of Wed Excavation Dia.of Wel! Casing mestic/Private ❑ Gravel Pack ©Tracy Type of Casing Specifications blic Cl Other n Delta Depth of-Grout Seal Type of Grout gation —Approx. Depth l I Eastern Surface Seal Installed by , - r Work Done ❑ Type of Pump H.P. State Work Done Destruction ❑ Well Diameter Se)Gng Material(top 50') Depth ler Material (Below ') OF SEPTIC WORK: NEW INSTALLATION 1.1 -REPAI ADDITION [Or-DESTRUCTION I I (Nb septic system permitted if public sewer is available within 200 feet.) tallation will servb: Residence Commercial_ Other mber of living units; , Number of aracter of soH to a depth of 3 feet: Water.table depth i 1C TANK ❑ Type/Mfg Capacity No. Compartments TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Pfopertv.Line THING LINE No.&Length of lines Total length/sae ER RED ❑ Distance to nearest: WellQ I Foundation Property Line i AE ` 'AGE PITS PK Depth Size Number _ IPS ❑ Distance to nearest: Well Foundation_ /� - Property Line .5 ` ?OSAL PONDS ❑ i ,eby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws, and i and regulations of the San Joaquin Local Health DBtrict- ie owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued.I shall not CG' 4oy any person in such manner as to become subject to workman's compensation laws of California.-Contractoes hiring or sub-contracting signature ft.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- laws of California." applicant in for a it nspections, Complete drawing on reverse iA.A Title: !IJ -- --� Date I Az4te FOR QEPARTMEf11T USE ONLY - Ao-ation Accepted by Cmk�L�Q'J Date JrArea !` of Grout Inspection byD to Final Inspection by � Date fttional Comments: kk 4664MI ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy `l slicent- Return all copies to: Environmental Health Permit/Services 1601 E. Hezalinn Ave., P.O. Box 2009,Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C K# RECEIVED BY DATE PERMIT NO. INFO IatY.mins} _ t i