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APPLICATION FOR PERMIT <br /> / SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (208) 466.6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Tripkatel <br /> Local Homo or 0 permit to CwWuct <br /> .This <br /> tion is <br /> � ��Son Joaaquuin County 41 Sam Ordinance No.5W fat few a No 1862 Iw►vdupwr p and the Rules and Rig taro of the 6 Jaoaquin <br /> made In complwice � <br /> Local Health oi.tritt. ! 3✓L <br /> Job Addres 7 () _ City Lot Sue PM <br /> 13 Ownen'a Name Phone <br /> Contractor Address License NoLf 3 k Phone a <br /> TYPE OF WELL&LIMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR IJ OTHER ❑ i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAI.FLD. PROP,LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial CI Open Bottom ❑Manteca Dia.of Wed Excavation Dia.of Well Casing i <br /> O Domestic/Private L7 Gravel Pads 0 Tracy Type of Casing Speuticationo (" I <br /> t <br /> I'I Public 1-1 Other I 1 Delta Depth of Grout Seat Type of Grout <br /> I I Irrigation _Appiox.Depth I I Eastern Surface Seal Installed by — <br /> Repsr Work Done U Type of Pump H.P. State Work Done, <br /> Well Destruction CI Wed Diameter Sealing Material It 5K) - <br /> _ <br /> Depth _ FAW Material IB _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ff DESTRUCTION I I (No septic system perrrwttel if public sewer is <br /> available within 200 1"L l <br /> Installation will serve: Residence_ Com marcial <br /> Number of kvwq units:I Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth_ <br /> SEPTIC TANK LlType/Mfg Capacity_ No.Componments <br /> PKG.TREATMENT PLT.1.1 Method of Disp9sal <br /> Distance to nearest: Wed�_Q_ Foundation /b 0 Property Lime _ <br /> LEACHING LINE Cl No.A Length of lines Total length/size 0 <br /> FILTER BED 11 Distance to nearest: Wed ZJ2- Foundation �Li!L- Property Line 0 <br /> SEEPAGE PIT 1 I Depth YX -1S_ Number �t n <br /> P A'LG. l I Distance to nearest: Well/00 Foundalion L1L4)__ Property Line_Qs� <br /> DISPOSAL PONDS CI <br /> I hereby comfy that 1 have,prepared this application and that the work will be done in accordance with San Joaquin.ounty,ordwwrces,erase lawn,and <br /> rules and regulatiore of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"1 cenlfy,that in the performance of the work la which thio permit isoaauod,I shad not <br /> employ any person in such manner as to become subject to workman's compensation taws of California.-Contractors hiring or sub-coruracting signature <br /> candies the following:"I comfy that in the performance of the work for which this permit is issued,I shah employ perwns subK :to vvorkma►'s compenu. <br /> tion laws of Ce ifornia." <br /> The applicant mustqA Ior all reqi0sel inspections.C to diewing on reverse side. <br /> Signed X__r1 �_ Title:, _ Dow: <br /> F USE ONLY n �► i <br /> Application Accepted by Date Ates <br /> .;rFn- o .G.lo <br /> Dau / <br /> /Pn Grout Inspection by �' ' at Inspection by <br /> Addnional Comments: I <br /> 1 Stk 466 6761 ❑Lodi 36&3621 ❑Manteca 623.7104 0 Tracy 635•M <br /> Applicant• Rerun all cope to:EnvvonmerlW Heelth Pemtit/Services 1601 E.Hazatton Ave., P.O.Box 2008,Stk..CA 9=1 �+ <br /> FEE AMOUNT DUE AMOUN REMITTED CASH RECEIVED BY DATE PERMIT ND. <br /> INFO <br /> lir,.34 ixty , „ 3 IJ0 <br /> fM 1•� <br />