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APPLICATION FOR PERMIT T, <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. H/1ZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 r, <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUE <br /> 5t <br /> (Complete in Triplicate) Thi,application is <br /> made to the San Joaquin Local Health Distrx t for a permit to construct all/pu ins' d the work he described• <br /> Application is hereby county Ordina ce No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> PP // �- <br /> made ir.compliance with can Joaquin C tY 1 _l / <br /> Loca! Health District. 8 (�/ N� L PM <br /> City_�JLot Size <br /> SI .� C 9.� Phone <br /> Job Address 1 <br /> A-a �` Address ' <br /> Owner Nana License Phone <br /> tt t License No. <br /> Address N7 ❑ DESTRUCTION D tA0N r701�N J <br /> Co>>tractor — WELL WELL REPLpCEMEOTHER ElN <br /> TYPE OF WELL/J. SYSTEM REPAIR G PROP LINE <br /> --r PUMP INSTALLATION G DISPOSAL FLD-� <br /> SEWER LINES �� PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK �— AGRICULTURE WELL _ OTHER 1}11ELL`— <br /> --�—� FOUNDATION � <br /> —�� PROBLEM EA CONSTRUCTION SPE C1FlCA ONS Da, of Well Casing INTENDED USE TYPE OF WELL <br /> ❑ Manteca Dia. of Well Excavation G Specifications <br /> C Open Bottom Typo of Casing <br /> fol <br /> F1 industrial ❑ Tracy � I`� 1Q Type of Grout <br /> Domesti - Gravel Pack Depth of Grout Seal <br /> ❑ Other ❑ Delta <br /> �] Public Surface Seal Installed by <br /> �4pprox. Depth L] Eastern tate Work Done wt <br /> ❑ Irrigation H.P. g Gw I <br /> Type of Pump, Q <br /> Repair Work Done ❑ Sealing Material (top 50) ezey� <br /> e11 Destro tin Well Diameter; - <br /> � _ Filler Material )Below 50'I stem permitted if public sewer is 1 <br /> , I Depth _ -�— DESTRUCTION D (No septic sy. <br /> 11061"0 available within 200 feet.) <br /> - TYPE OF SEPTIC WORK.: NEW 1NSlALLATION ❑ REPAIR/ADDITION ❑ <br /> Commercial� Other — <br /> installation will sere: Residence Water tabla depth <br /> Number of living units: Number of bedrooms 1— <br /> No. Compartments <br /> Character of soil to a depth of 3 feet: --��— <br /> �ty� <br /> ❑ Type/Mfg Method of Disposal �.--- <br /> SEPTIC TANK Line — <br /> PKG. TREATMENT PLT. ❑ Foundation_ Property — <br /> Distanco to nearest: <br /> ------ <br /> Total length lsize_ — <br /> ❑ No. & of lines — Property Line�— <br /> LEACHING LINE Well _ Foundation <br /> FILTER BED ❑ tante to nearest: <br /> Number_1 <br /> ❑ Depth Size Property Line�1 <br /> SEEPAGE PI Well Foundation�— <br /> SUMP Cl Distance to nearest:. tate laws, and <br /> POSAL PONDS ," ❑ <br /> if that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances. s <br /> I hereby'cett y <br /> rules and regulations of.the•Sas s°natureLocal <br /> en-ifiosth6 follow ng: "1 certify that in the performance of the work for which this permit is issued, I signature <br /> shall not <br /> Home owner or licensed agent 9 nsatron laws of California.hall employ hiring or subto workman's gcomPef� <br /> employ any person in such-;nanner as to become subject to workman's comps <br /> certif es the following: ,,I certify that in the performance of the work for which this permit is issued, <br /> tion laws of California." <br /> The applicant st call for all required i tions. Complete drawing on reverse side. Date: <br /> rale: <br /> SignedFOR DEPARTMENT USE ONLY <br /> Area <br /> Date <br /> 1 Date rL"L-�✓" o <br /> Application Accepted by � �/Final Inspection by <br /> 16L� <br /> Date <br /> Pit or Grout Inspection by <br /> } ❑ Manteca 823-2104 ❑ Tracy �`r& ' yt/t��J <br /> Additional Comments: �--� tk., CA�1 <br /> ❑ Stk 466781 ❑ Lodi 369-362 - <br /> Ir nt Return all c pies : Environme�I Health_ Perrtvt/Services�l�} E. Hazelton Ave. P.O• Box 2009. <br /> Al,' � �,.o-r✓►� c's"""'-�°'' ;Z.-- -`. <br /> Rs-, DATE PERMIT NO. <br /> CK RECEIVED BY <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> . EH 13.2A(REV.1`a <br /> EH 14-26 <br />