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APPLICATION FOR PERMIT <br /> SAN JOAQU;I'N LOCAL HEALTH DISTRICT 30 3S <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 . <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Heakh District for a permit to construct and/or install the work herein this application is <br /> No.549 for sewa e or No. 1862 for well/ and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance .9 <br /> -Local-Health District. :�j tn. <br /> mCity Lot Size PM— <br /> Job Mu - - 77 <br /> Phone --03-) S <br /> Address <br /> ti owner"ame U <br /> Address Phone M <br /> r. License"- <br /> Contractor } r, <br /> PE OF WELL/PUMP: i -NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION LJ <br /> Z . ,- <br /> PUMP INSTALLATION El SYSTEM REPAIR 0 OTHER 0 <br /> — <br /> DISTANCE TO'N5AREST: SEPTIC TANK qE%WER.LINES. DISPOSAL FLD. PROP. LINE <br /> _ — <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> - <br /> INTENDED USE TYPE,or WELL PROBLEM AREA -CONSTRUCTION SPECih6ATI0N5; <br /> 4" <br /> ❑ <br /> Dia. of Well Casing Industrial El Open Bottom, 0 Manteca t. Dia. of Well Exca4iti6n,' <br /> Specifications <br /> E] tic/.PiI 0 Gravel Pack'-----0 Tracy Type of Casing--­L-� <br /> ornes _ . _ t - - Type of Grout <br /> Depth Jdrl'out-Seai A <br /> 171�Qthe C3 Delta <br /> 0 Public -, L 0 - J <br /> Irrigation :astWrn-'-- Surface Sea[ Installed bwy--- � <br /> Irri ---Approx. Depth I - <br /> A , —• �Statg-W6rk Done <br /> Repair Work Done �71 Type of Pump <br /> Well Destruction Ll Well Diameter Sealing Material (top <br /> bepth. Filler Materiali(Bel"50'.) <br /> INSTALLATION [7 R ITION Cl DESTRUCTION C3 (No septic'system permitted if public sewer is <br /> -,SEPTIC WORK: -NEW INSTA REPAIR/ADDITION feet.) <br /> ,TYPE OF available within <br /> Commercial— Other <br /> Installation will serve: ResIdence <br /> � s .Num�er of living units: bedrooms of bedrounits: <br /> Character of soil to a depth of 3 feet- Water table depth <br /> No. Compartments <br /> 9, <br /> SEPTIC TANK El Type/Mf Capacity-zzVLQ— <br /> Method of Disposal <br /> -PKG. TREATMENT PLT. 0 <br /> Distance to nearest; Well Foundation Property,Line <br /> ATotal length/size V <br /> 'LEACHING LINE D No. 81 Length of line <br /> FILTER BED E Distance t <br /> Foundation Property Line 0 <br /> r <br /> Sim Number <br /> SEEPAGE PITS El Depth -2-�L- <br /> P IIZI 6117A� Foundation 40�Property Line <br /> SUMPS [J Distance t��earest:---,�. W <br /> ,DISPOSAL PONDS El <br /> -1 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 /> subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> ;emplcertifies the following:"I certify that <br /> oy any person in such manner as to becomes the performance.; of the work for which this permit is issued,I shall employ p6rsons subject to workman's comperisa- <br /> ' in <br /> ltion laws of California." <br /> di t, Complete drawing on reverse side. <br /> The applicant ust call.fo.r all r quire ins c ions. t . ? <br /> i Title: 154 Ital jz-n Da <br /> iSign:d <br /> OR DEPARTMENT USE ONLY <br /> -3 <br /> 4 Application Ac:cepted by .Date Area <br /> Fit or Grout Inspection by ate Final inspection by D <br /> al-Comments: <br /> Addition M <br /> ?E] Stk- 466-Ml El Lodi, 369-3621. ❑0 Manteca .823-7104 0 Tracy 835-., P.O. Box 2009, Stk., CA 95201 <br /> Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave <br /> FEEAMOUNT DUE AMOUNT REMITTED CASH CK* RECEIVED BY DATE PERMIT"NO. <br /> INFO C- <br /> + EH 13-24 1 REV.1/857 <br /> E14 1428 <br /> Lop <br />