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APPLICATION,FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES'll YEAR'FROM DATE ISSUED,:, <br /> (Complete in Triplicate), <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work h rein described. This application i& a. <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules andAegulations of the San Joaquin <br /> Local Health District. <br /> Job Address 4A) City'�� Lot Size-, PM <br /> bOwner's Name 1' _"Addres 6 Phone <br /> V01 <br /> ContractorA - Address License NoM9a,,F`honfn67>2 2 <br /> TYPE OF1,T`VEL0PUMP _#1_' -WELL _E1 WELL REPLACEMENT 13 DESTRUCTION D <br /> PUMP INSTALLATION 171 SYSTEM REPAIR El OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES" - DISPOSAL FLD._ PROP. LINE <br /> I I FOUNDATION'-. AGRICULTURE WELL - OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WEL$;�__,AQBLEM AREA- -GONSTRUC-T-IE)N"SPECIFICATIONS <br /> Ll Industrial Ll Open Bottom 0 Manteca Dia, of Well Excavation Dia. of Well Casing <br /> D Domes ic/Private D Gravel Pack 0 Tracy Type of Casing Specifications : <br /> T <br /> L1 Public ID Other 0 Delta Depth of Grout Seat Type of Grout <br /> 0 Irrigation ---Approx. Depth El Eastern Surface Seal Installed by <br /> Repair Work Done C Type of Pump H.P. State Work Done <br /> Well Destruction El Well Diameter t Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION EJ REPAIR/ADDIT L1 STRUCTION No septic system'permitted if public sewer is <br /> ailabi ithin 21]6 feetj- <br /> Installation will serve: Residence Commercial Other <br /> Numberlof living units: - Number of'bedrooms <br /> Character of soil to a depth of 3 feet: er table depth <br /> SEPTIC TANK 17 Type/Mfg i Capacity No. Comparkments <br /> PKG. TREATMENT P' F1 Method of Disposal <br /> Distance to nearest: Well t Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BL) r] Distance to nearest: Well Foundation Property Line <br /> T__ <br /> SEEPAGEWITS 171 Depth -SiZ, <br /> e Number <br /> SUMPS Li Distance to nearest; k Wella Foundation Property Line <br /> DISPOSAL PONDS El <br /> I hereby certify that I have prepared this application and that th'e'work will be I done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. I <br /> Home owner or licensed agent's signature certifies the following- "I certify that in the performahce of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting 4ignature <br /> certifies thb following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> 4 , <br /> applicant%ust call for all re uire JImplete drawing on reverse side, <br /> The d in ctions,C <br /> Signed X Je� Title: Date: <br /> OFJ DEPARTMENT USE ONLY <br /> y [,qf97 Area <br /> Application Accepted b Date <br /> Pit or Grout Inspection by Date <br /> Date Final Inspection by <br /> Date <br /> Additional;Comments: <br /> 0 Stk 466-6781 17 (odi 369-3621 C] Manteca 823-7104 E Tracy 835-6385 <br /> Applicant.iReturn,allcopies.to;-,Environmental-Health:Permit/Services4 601-E.-Hazelton-Aver;P:O:-Box-20097-Stk:,­CA-952011 <br /> fi <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED By DATE PERMIT NO. <br /> EN13-24 4REV.i i a 5S <br /> EH 4-25 <br />