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APPLICATION FOR PERMIT <br /> SAN JOAIQUIN'LOCAL HEALTH DISTRICT <br /> y 1601 E. i-IAiZILTQN AVE.`, STOCKTON, CA. <br /> } n n. (209) 466-Ml <br /> PERMIT EXPIRES 11 YEA FROM DATE ISSUED ,,, k ,V <br /> " iComplete In T.riplicatel <br /> Appliiation 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 /> 49 <br /> made in compliance with San Joaquin ounty Ordinance N 5for sewage.or,No..1862 for well/pump and the RUIes and Regulations of the San Joaquin <br /> L"ocal,Healih`Uistrict.. � �; <br /> 7 SII f e,; CityG- I J it PM <br /> Jab Address 1 U t Lot Srze <br /> 4 D <br /> 12 <br /> Owner s Nam �'?�/'t� .' toss 'tPhone yyy <br /> Contractor Address ['] �- License No3 E'hotie ? <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT❑ DESTRUCTION ❑ ? ; <br /> t <br /> I - PUMP INSTALLATION ❑ , •;�J�vr�SYSTEM REPAIFi !`'t"+aOTH1=R,❑ i�*„�y <br /> w, rDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. -DISPOSAL FLD. r'- PROP;LINEw°s <br /> I f eC NI ATION GR <br /> _ AECULTU_RE WELL OTHER WELL i< 'PITS/SUMPS <br /> `INTENDED USE, T TYPE OF WELL ^. PROBLEMAREA' CONSTRUCTION SPECIFICATION! J r <br /> L7 <br /> Industrial,,}' ❑ Open..Bott6m ❑ Manteca Dia. of Well Excavation 'Dia: of Well Casing <br /> ' ❑'Domestic/Private '; ❑ Gravel Pack° ❑ Tracy Type of Casing Specifications <br /> i ❑ P4rblic !' El OiherLl Delta Depth of Grout`Seal Type of Grout <br />' <br /> 1:1 In ---Approx. Depth 171 Eastern Surface Seal Installed by F_ ' <br /> Rep air,Utilo►k Done: 0... Type of Pump-`- H P, rG_' �Stafe"Work Done <br /> Well Destruction ❑ Well Diameter A.'- Sealing'Material (top 50'1 i <br /> I Depth filler Material (Below 501 "I <br /> TYPE: OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is t <br /> ,it available within 200 feet.) <br /> Installation will serve: 'Residence `_ 'Commercial,— -Other <br /> d.: <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/hllfg ro Capacity No. Compartments " <br /> PKG.TREATMENT PLT. ❑ ! Mathodof Disposal ' <br /> Distance to nearest: Well __ Foundation Property_Un_eA --' <br /> i LEACHING LINE ❑ No. & Length of lines Total length/site 'i', <br /> 1 <br /> FILTER BED + ; 'j D Distance to nearest: Well Foundation, Property Linet'l-- <br /> i SEEPAGE PITS ❑ Depth'[` Size Number ,.b, �, } <br /> 4 <br /> ' SUNIPS ❑ Distance to nearest: � Well Foundation Property Line <br /> DISPOSAL'PONDS - <br /> t, » I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances statelaws, and <br /> rules and regulations of the San Joaquin Local-f9ealth District. j Y <br /> Home owner or licensed agent's signature certifies the following: "1 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 6eco4iu6iect to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of,the work i&which this permit is issued,1 shall employ,persons subject to workman's compensa- r' <br /> "tion laws of California." <br /> 1 v The:applicant tall for all required inspections Complete drawing on revsrse.side' <br /> I Signed' Title: Date: <br /> : POR DEPARTMENT'USE ONLY , <br /> j + - 2- <br /> Application Accepted,by F Date" 9�"T Area' <br /> I <br /> Pit or Grout Inspection by Date s Final Inspection by ' Date <br /> tAdditional Comments: _ ) <br /> El Stk 466-6781.. Lodi 389 3621 ❑'Manteca 823-7104.- ❑ Tracy x 835-6365' <br /> Applicant Return all c pies to:. Environmenaf,He'alth Prmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IIS <br /> FEE AMOUNT DUE AMOUNT-REMITTED CK RECEIVED BY DATE PERMIT`NO. <br /> INFO CASH <br /> r EH 13-241AEV.1/e51 <br /> i EH 14-28 <br /> +p <br />