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n <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (2091466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is he"eby 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 ScTny Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. Vila- _V <br /> Job Address �'1-4il�� VJ . PC�Qlf1 �{� City Lot Size PM <br /> dtlOb tc - 4icEi-2,Q®-&A <br /> Owner's Name V-e�, Address .� . ,'S1<.D � 4 n Phone <br /> Contractor_. _ Address M gr__3 f �� icenseallo _Phone <br /> TYPE OF WELL/PUMP: NEW WELL�❑).Z } WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION `AGRICULTURE WELL OTHER WELL PITS/SUMPS 4 <br /> INTENDED USE _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial N� ❑Open Bottom ❑ Manteca Dia. of Well Excavation Dia"of-Well Casing <br /> L Domestic/Private f ❑"Gravel Pack ❑ Tracy Type of Casing C Specifications <br /> F1 Public IfFn Other ❑ Delta Depth of Grout Seal Type of Grout <br /> 1 1 Irrigation _-.Approx. Depth I I Eastern Surface Seal Installed by ' <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth ,Paler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] :REPAIR/.ADDITION DESTRUCTION i I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other t <br /> Number of living units: Number of bedrooms'""° <br /> Character of soil to a depth of 3 feet: Water table'depth---%'' . <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKd. TREATMENT PLT. ❑ Method of Disposal <br /> Distance'td nearest: 'Well' ' ' """Foundation "awP'""'"' Property Line <br /> r <br /> .01 <br /> r2 P%7 <br /> c <br /> LEACHING LINE �I No. & Length of lines fN05 Total length/size <br /> FILTER 9ED ­ ❑- Distance to­neares'tT 1Nell 'r"� Fouridation' Property Line <br /> SEEPAGE PITS I-l-e�bepth Size, Number A <br /> SUMPS ❑ Distance to nearest: Well¢ Foundation_ .'. fPropert -Line <br /> DISPOSAL PONDS If <br /> I hereby certify that I,have prepaied 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 a'gent'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 suk'ti manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature \w <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa-� <br /> tion laws of alifornia." <br /> s y 4 <br /> The,appr must c I or all r uired inspections. Complete drawing'o reverse side. f � <br /> SigAad Title: - 1 tt Date <br /> FUR DEPARTMENT USE ONLY <br /> Application Accepted byI I a f `pate vim' <br /> - Area <br /> f <br /> Pit or Grout Inspection by Data fFinal dnspection by Date <br /> Additional Comments: .1 r <br /> 0 Stk- 466-6781 ---❑-Lodir_369-3621 0 Manteca--823=7104--• 10-Tracy-835-6385-- <br /> Applicant Return all copies to:.Enviropmental Heatth Permit/S�rvices i6U1 E..HazeltbwAve., P.O. Box 2009, Stk., CA 95201 <br /> INFO ! MOUNT pUE ' AICKV <br /> MOUNT REMITTED` i` GASH RECEIVED BY DATE PERMIT'N0. r <br /> ♦.EH 13-24(REV.,/K5) fr''f 't` .• .�` ►.,4 l -, {..1; '1�7t.� ��ip'r/`*�7_i._ 4 fM _. .. dY�1 <br /> EH 14-24 {1°0� 70, V <br />