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APPLICATION FOR PERMIT <br /> 166 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Teleph6ne (20g) 466-6781' <br /> PERMIT EXPIRES. '( YEAR FROM DATEASSUEV- <br /> ...(Complete:in 'Triplicate) <br /> Application is hereby mE�cle to the San Joaquin Local Health District for a permit to construct and/of install the work herein d'sdri.bed This applicaiion is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No,1862 for welll�p&np and the Rules and Regulations of the San Joaquin <br /> Local Health District., <br /> 'A <br /> 0 Vy 'G KF <br /> Job Address __ <br /> city 1%;�� Lot Size PM <br /> 0 <br /> Owner's Name Address I",- Phone <br /> Contractor's Name License No. q <br /> Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION 0 <br /> PUMP INSTALLATIONLl SYSTEM REPAIR OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK too SEWER LINES I DISPOSAL FLO. <br /> 4. i - PROP. LINE­ <br /> FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial F-1 Open Bottom El Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> $ Il <br /> Dorriestic/Private 0 Gravel Pa6 <br /> k L Tracy Type of Casing- Specifications <br /> , <br /> LJ Public E3 Other El Delta Depth of Grout Seal Type of Grout <br /> E Irrigation --Approx-' Depth 0 Eastern Surface S6al Installed by <br /> Repair Work Done L1 Type of Pump H.P. State Work Done "Ati <br /> Well Destruction El Well Diameter Sealing Material (top 501 <br /> Depth Ybs-' Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION Ll DESTRUCTION 11 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> 4 <br /> Number of living units:- Number of bedrooms <br /> Character of soil to a depth of 3 feet: t. -Water table depth <br /> SEPTIC TANK 111 Type/Mfg:, Capacity— No. Compartments <br /> PKG. TREATMENT PLT. 171 <br /> I '`jt Vethocl of Disposal' <br /> Distance to nearest:` Well Foundation—- Property--L-ine <br /> LEACHING LINE 13 No, & Length of lines �e <br /> Total length/sIz--- <br /> FILTER BED C1 Distance to nearest: Well <br /> Foundation <br /> Prope nel. <br /> SEEPAGE PITS 0 Depth 1—Siz, Number <br /> SUMPS 0 Distance to nearest: well F" <br /> ounclation Prop" Line <br /> DISPOSAL PONDS 11 <br /> I hereby certify that I have prepared this!application and that the work will bb.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 signatur-ii certifies the following: "I certify that in the performance of the work for which thig-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 the following:"I certify that in thi performance of the work for which this'permit Is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The appalican ust ca M for all requi d pections. Complete drawing on reyers?side. <br /> Signed Title: 4�0 Date: <br /> F0 DEPARTMENT' ONLY <br /> Application Accepted byD at Area <br /> Pit or Grout Inspection by Date _i;r7V�n Inspection b Date 71-.2 Z24T <br /> Additional Comments: <br /> 0 Stk 466-6781 0 Lodi 369-362I El Manteca 823-7104 !0 Tracy 835-6�385 - <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO CASHAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE' . <br /> 0 <br /> N <br /> MIT <br /> PEA " , <br /> 1 1 , <br /> EH 13241REV.10/831 ;I- .. <br /> EH 14-26 <br />