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APPLICATION FOR PERMIT 4 <br /> -� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON�AVE., STOCKTON, CA <br /> Telephone (20W-466-6781 <br /> PERMIT EXPIRES 1,YEAR FROM.-DATE ISSUED + <br /> {Corriplete)n 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.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address au6l­ P.-b city, f;C-q G Lot Size pM <br /> r.4r yt d <br /> Owner's Name Address e` Phone <br /> Contractor icy ,41" .1 ;( Address 00 License No. , Phone t <br /> TYPE;OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑,P, + <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER E3 <br /> DIST NCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> ❑ In ustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> E] c-.• <br /> DoesticlPrivate ❑ Gravel Pack D Tracy.,„„ '�. Type of.Casing Specifications <br /> ❑ Pu kic El Other 4 fl Delta Depthlbf.Grout Seal 1•--x-_ ,Type of,Grout Orr <br /> ❑ Irrigation --Approx. Depth '❑ EasterK Surface Seal Installed by ' <br /> Repair Work Done EI Type of Pump H.P. k State W ik Done <br /> Well Destruction ❑ Well Diameter t' —Sealing�Material-[top'50'•)-----' <br /> I Depth Filler Material (Below 50'),,¢ <br /> TYPEiOF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> „ ,- ........_.available within 200_feet.)_-. <br /> __ --»-Installatlon. ill serve:f. Residence-_��Commercial-_.;.,Other. - - <br /> J <br /> Number of living units�i:16"` Number of bedrooms <br /> _ C) <br /> Character o9 soil to aGlath of 3 feet: 4 Water table'depth <br /> SEPT'.0 TANK ❑ Type/Mfg Capacity {rD' <br /> t — �r}'� No. Compartments � ,n <br /> PKG.aTREATMIsENT-PLT. d 7 Method of Disposal U j <br /> s <br /> I Distance to nearest: Well�v�.� Fb undation 0a j Property LineZ-0 Jr— <br /> LEACHING LINE ; ❑ No. & Ldngth-bf`I es_ Total length/size S <br /> FILTER BED f Distance to nearest: "`Well Foundation� .Property Line <br /> SEEPAGE GE PITSr� p Depth •° Size 4 Number (° <br /> SUM pS i❑ Distance to nearest: Well Foundation I Property Line T <br /> DISPOSAL PONDS C <br /> I hereby cer{ify tha"t 1'Ytaveptepared'ttiis`a'pplicatioh and that the woik wilF be done in accordance with San Joaquin county ordinances, state laws, and - <br /> rules And regulations of the San Joaquin Pcal Health District. e <br /> Homef owner or licensed agent's signaturFe certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> 2tt.�employ drlyeperson in sueh nnanner as to.become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> cenifies'Uie following;"'I'certif�that in46 performance-of-the worklor vhicll this permit is}issued,I shall employ persons subject to workman's compensa- <br /> ' tiori`IaVvs of=C-Blifomia." *`.i .�w'"^"" "-;� f�`;• -- - Y ' <br /> ->"The applicart[mud ca"Iffor ie dins ctions. Complete drawing n reverse side. <br /> Signed' Title: ;/ �� _ Date: <br /> y : 1 <br /> i FOR DEPARTMENT USE ONLY //" <br /> Application'Accepted Y Date OSx �� Are v - <br /> er <br /> k <br /> Pit or�G rout Inspection'by Date 1" Final Inspection by iMt- K. Date <br /> Addition8l Comments: ' f f ' , <br /> ❑ Stk 466-6781 r ❑ Lodi 369-3621 ❑ Manteca 823-7104 I-] Tracy835-6385 <br /> Applicant Return::all copies to: Environmental Health Per'mit/Services#1601'E. Hazelton`Ave., P.O. Box 2009, Stk., CA 95201 + <br /> I' <br /> q FEry — 'U o CK# e <br /> rr INF . AMOUNT DIlE; ^AMOUNT REMITTED 4 CASH R*CEIVED BY DATE PERMIT`NO. <br /> 8 <br /> t <br /> w•EH-13-24"IReV:1�/ 51 - -1�•: ..F. _er —w�.—•.._------ ...—s-, _� •�,,,^... ......^ .-d* �e-e- �——...r�, .+. .—,r.�..-�..... ,.. <br /> EH 1428 - / C�. �..�0 �n <br />