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APPLICATION FOR PERMIT <br /> SAN JOAQUIN.LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE,STOCKTON, CA <br /> Telephone (209) 466-6* <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> T(Complete in Triplicate),: . <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No.W for sewage of No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address Lot <br /> 5 Size <br /> City PM <br /> Owner.'s Name A�ldress- Phone <br /> Contractor I N evyAddress P-0 Li 'WSy ;F Phone <br /> 77—PE OF WELL/PUMP: z cense No,- <br /> -9 <br /> �12W WELL 0 WELL REPLACEMENT 7- DESTRUCTION C3 <br /> PUMP INSTALLATION E SYSTEM REPAIR 0, OTHER D <br /> DISTANCE TO NEAREST:'SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD._ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL — OTHER WELL PITS/SUMPS <br /> 7— <br /> INTENDED USE TYPE OF WELL PROBLEM AREA_.CONSIRUCTION-SPECIF-ICATIONS4ii, --�----- <br /> ­_ffindustrial Y'Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> El Domestic/Private n Gravel Pack [I Tracy Type of Casing Specifications <br /> F] Public L Other C1 Delta Depth of Grout Seal Type of Grout <br /> 0 Irrigation _ Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done E Type of Pump H.P. State Work Done <br /> Well Destruction El Well Diameter Sealing Material (top 501 <br /> Depth Filler Material {Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION C REPAIR/ADDITION 0 DESTRUCTION El (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> ation will serve: ':I <br /> Instal-liesidence Com/6(fr—,om,r�a—rcial I-f-"Other 4S, <br /> Number of living units: Number�/Tfb7,,V, <br /> & <br /> Character of soil,t6 6-depiTh of 3 feet: Water table depth <br /> SEPTIC�TANK M-1,Type/Mfg rCapacity-. No. Compartments <br /> PKG. TREATMENT PLT. L3 <br /> _-, Method of Disposal <br /> Distanc to nearest:,,: <br /> I <br /> Welf Foundation Property Line <br /> LEACHING LINE No. & Length of lines de <br /> 1 engtnes 1. Total length/size Zeq <br /> FILTER BED E2 Distance.to nearest: Well -< Foundation Property Line <br /> SEEPAGE PIT§______X76_.pth Size Number I/ <br /> SUMPS' e <br /> E1 Distance to nearest: Well ,�a Foundation Property Line e <br /> DISPOSAL PONDS El <br /> 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, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies tfii;,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- <br /> tion laws-&f California." <br /> The applicants- t all for I require inspections. Complete draw-Ing on reverse side. <br /> Signed 2 <br /> Title:' Date: ed <br /> FOR DEPARTMENT USE ONLY <br /> y AAAAAz 136te 3- <br /> Application Accepted 6" C.,�r_ F2 Area —_o4 <br /> Pit or Grout Inspection by <br /> r`V <br /> Date Final Inspectio -by hl%6 Date <br /> Additional Comments: <br /> 11 Stk 466-6781 El Lodi 369-3621 El Manteca 104 LJ Tracy 835-685 <br /> ,AppIicgiit - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave,, P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK# <br /> INFO CASH RECEIVED BY DATE PERMIT NO. <br /> EH 13-24{REV.1 a 51 <br /> EH 14-26 _70� O c> rs <br />