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r � <br /> Y <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEILTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is heteb made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> App Y p ; <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for, �/Pump and the,and.Regulq(ns-ZZo Satn�Jaoagwn <br /> Local Health District. & p/N/IJ•'`• //�/ iv f <br /> t5., Y Res R <br /> 4A4 ity a!a11�Q Lot Size PM <br /> Job Address <br /> Phone <br /> tiC3'� A dress e <br /> Owner's Name $13,95egt9 <br /> PS p Ltd Va License No. _Phone ; <br /> Contractor 1�� R� Address § <br /> PLACEMENT ❑ DESTRUCTION ❑ -� •L� 'R <br /> TYPE OF WELL/PUMP: NEW WELL 13 WELL REOTHER �R�`r' <br /> PUMP INSTALLATION 11 SYSTEM REPAIR LDOTHER <br /> LINE <br /> SEWER LINES ��— DISPOSAL FLD. <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WEL'LPITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL �' <br /> PROBLEM AREA G�STiil1CTION SPECIFICATIONS <br /> IIVTENDED'IJSE TYPE OF WELL <br /> EDia• of Well Excavation . DiWell-Casing Q' <br /> ❑ <br /> Industria ❑ Operi Bottom ❑ Manteca } —.,Specifications <br /> -ia.r I Type of Casing O <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Depth of Grout Seal '� Type of Grout <br /> FI Public f Other C1 Delta * _ <br /> Approx. Depth t I Eastern Surface Seal Installed <br /> N.P. by <br /> I I Irrigation <br /> Statell ork Done <br /> Repair Work Dona- ❑ Type of Pump Sealing Material (top 50') U <br /> { <br /> Well 41Destruction ❑ Well Diameter Filler Material (Below 501 <br /> Depth <br /> TYPE OF SEPTIC WORK: <br /> NEW INSTALLATION REPAI#(ADDITION i I DESTRUCTION t I aivailablefwi within feet.) if publicsewer is ~ <br /> - ? <br /> Installation will serve: Residence Commercial Other_ <br /> t x' <br />} <br /> -.Number of_living units: Number of bedrooms,. � " Water table depth " <br />! Character of soil to a depth of 3 feet: <br /> LR { Capacity Z� r No. Compartments 2 <br /> SEPTIC TANK Method of.Disposal <br /> PKGS TREATMENT PLT. ❑ r t t <br /> Property Line <br /> Distance to nearest: Well; Oa Foundation „ <br /> t , <br /> Total length/size <br /> LEACHING LINE �No. & length of lines t Property Line t <br /> ❑ Distance to nearest: Well Foundation <br /> FILTER BED i — <br /> ' Number � t <br /> SEEPAGE PITS 11 Depth Size ` t <br /> Foundation Property �y,4 <br /> SUMPS Ll Dist <br /> ) an to near st: Well <br /> � <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with an Joaquin county ardinarces, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> s � N, <br /> ., <br /> Home owner or licensed agenYs'signatura certifies the following: 1 certify that in the performance of the work for which this permit,is issued, signature <br /> 's a no <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor'sensrsub'ect to wosu Qkmanlscompensa- <br /> I certifies the foNowing: "I certify that in the rformance of the work for which this er s issued, I shall employ p 1 r •., v <br /> x, <br /> 4 <br /> tion laws of California." 4 <br /> .., <br /> k The applicant mu li for all equtred in ctions. Complete drawing on reverse side. <br /> Date: <br /> Title: � .. <br /> Signed X ` <br /> FOR DEPARTMENT USE ONLY _ n <br /> _ -4 Date Area �1 <br /> Application Accepted by <br /> Pit or:Grout Inspection by Data <br /> Final Inspection by Date <br /> Additional Comments: , <br /> ❑ Stk 466-6781 D Lodi 369 3621 ❑ Manteca 823-7104 ❑ Tracy 835-638 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.0,9ox 2009. Stk., CA 95201 <br /> CK RECEIVE(] BY DATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO 701-- <br /> 3 <br /> j <br /> + Z 13-24 IAEV.t/n 5f '/�) <br /> EH 14-26 l v <br />