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APPLICATION FOR PERMIT w SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209t#C6.T7"M~ LN�qV-'3'\-LZ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ► (Complete in Triplicate) Application is hereby made to the Sar'' Joaquin Local Health District for a permit to construct andlor install the work herein dr Jr:ribed. This application is +trade in cnrnpliunco with Safi Joaquin County Ordinance No. 649 lot sewage or No. 1862 for wellipump and the Rules and Regulations of the San.Joaquin Local Heafth District. i Job Address _. city Lot Srze _. PM Owner's Narttr _ _ G _ Address��\ �'✓ _ Phone -a-U Contractor _L _ _ Address License No. _ Phone _ I YFL OF WELL/PUMP _ NEW WELL C WELL REPLACEMENT C1 DESTRUCTION C PUMP INSTALLATION n SYSTEM REPAIR C1 OTHER C DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. ,_ PROP. LIME _ FOUNDATION _ AGRICULTURE WELL _OTHER WELL __. _ _ PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I I ludusuiat I I Open Bottom ❑ Manteca Die. of Well Excavation _ - O a. of Well Casing ,1 Domestic/ Private C) Grave Pack CJ Tracy Type of Casio 9 - Sprrci}ications I'I Public n Other I I Delta Depili of Grout Seal _- Type of Groul_. I Irrigation _•Aplisox, Depth I I Eastern Surfaca Seal Installod by Repair Work Dore f= Type of Pump _ H.P.._ — Stare Work Done Well Destruction U Well Diameter SrIhnq Material {tap .50,1 _ Depth . Filler Material IRelow bo') OF SEPTIC. WORK: NEW INSTALLATION LPAIRIADDITION I : DESTRL c system permitted if puhlii; sewer is within 200 feet.) r Installat.on w111 terve: Residence— rCorrnrWrcral _ Other f , Number of living units: _ Number of bedrooms I Character of soil to a depth of 3 feet: _._ _._ _ Water table depth— SEPTIC epth_SEPTIC TANK ❑ Type/Mfg Capar-ity_ No. Compartment. PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well , _-_ Foundation _ Prur}arty Line LEACHING LINE ❑ No. R Length of lines - _ Total length/size—. - FIL TER BED U Distance to nearest! Well Foundation Property Line SEEPAGE PITS I I Depth _Si:@ .__ Number SUMPS Ll Distance to nearest: Well Foundation Property Line - DISPOSAL PONDS I I I I hereby certify that I have prepared this application and that the work will be done ui accordance with Sin Joaquin county ordinances, state laws, ib" rules and regulations of the San Joaquin Local Health D;Witt_ Home owner or licensed 80ent's signature certifies the folowing: "I certify that in the perlonnanco of the work for which this permit is issr:ed, I shall not employ any porson in such manner as to become subject to workman's componsation laws of California_" Contractor's hiring or sub -contracting signature certifies the following: "I certify that in the performance of the work for which INS permit is issued, I shall employ persons subjnct to wDrkman's compensa- tion IBws of California " Tira upplicaloyfrus3 call for all requ' d ins c jilfcompiate, drawing on reverse Gide. Signed 0: r e: — —. — Date: FOR DEPARTMENT USE ONLY ,�¢ Application ACcopted by Dole _ L4 t� a i Pit nr Grout Inspection by f Date____-_-- Final Insnertrsn /�/!r/9 Addilianal Commonts 4 ��/ ✓�fF��ary iJ /S"—. c l/�/ /t . _ U Stk 466 Ml O Lodi 386-362 O Manteca $23 7104 r Tracy 835-6385 Applicant - Re u,r ail Copies to: Environmental Health PormitfServices 1601 E. Hazehon Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K M INiO GASH RECE'JED BY PATE PERMIYNO. .. EH 11741 REV. r y a!,'�✓ t �Q f� � 4n [Y "�L EH 7428 ___ Y `• �-T �/ i7'^� Y - O 7 - d / T 7