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r„4 APPLICATION FOR PERMIT 3 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1 <br /> 1601 E. HAZE i ON 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 Health District for a permit to construct and/or install the.work-herei his application is <br /> App' Y <br /> 'made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rule's-and Regulatiori's of the San Joaquin <br /> Local Health District. <br /> Ir O PM <br /> Pom' City Lot Size <br /> Job Address _ <br /> Address <br /> Phone <br /> Owner's Name <br /> �f License No. Phone <br /> Contractor Address J Address <br /> WELL REPLACEMENT ❑ DESTRlfC7 N Ll <br /> TYPE OF WELL/PUMP: NEW WELL ❑ SYSTEM REPAIR ❑ - OTIVER,-.C3 , r—.,�-�--_— <br /> PUMP INSTALLATION ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL Y PITSISUMPS <br /> e 11� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA Dia. of Well <br /> Excavation <br /> SPECIFICATIONS pia. of Well Casing <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I <br /> e of Casing Specifications <br /> ❑ Domestic/Private 11 Gravel Pack ❑ Tracy T Yp g Type of Grout 6 <br /> f"1 Public n Other F] Delta Depth of Grout Seal C <br /> I ! I Irrigation .Approx. Depth l 1 Eastern SuFface Se instaM �y <br /> H P State Work Done <br /> Repair Work Done El Type of Pump l <br /> Well Destruction ❑ Well Diameter Sealitenal <br /> + r <br /> Depth lker Material-18elow 601 <br /> TYPE OF SEPTIC WORK: NEW INSTALLA ON l 1 RIEPAIRIAODITION l 1 DESTRUCTION I I (No septic system <br /> thin m emitted if public sewer is <br /> installation will sive: Residence�'' f l.ommercial her <br /> f - 9Q / <br /> !Number of livingjunits: Number's b d oa �� — Water table depth s <br /> Character of soilito a depth of 3 feet: ' <br /> ' (� ,tJ� Capacity -kL <br /> No. Compartmenits <br /> SEPTIC TANK t� ype/Mfg <br /> 4 ,,! I ' V Method of Disposal <br /> PKG. TREATMENT PLT. 111 4) f Property Line �Q 1/ <br /> Distance to nearest: ' Well Foundation��. I <br /> Totallens gth/size} <br /> LEACHING LINE No. & Length of lines <br /> 7. Foundation d Property�ine <br /> FILTER BED El Distance to nearest: Well-i <br /> I <br /> Size Number + <br /> SEEPAGE PITS iDepth _ - <br /> SUMPS, y` "F Ll Di"stance to_nearest: Well��`_'�foundation Property'Line t <br /> � I <br /> DISPOSAL PONDS ❑ <br /> I 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. I <br /> Home owner or licensed agent's signature certifies the following: "t certify that in the performance of the work for which this permit is issued, l shall not <br /> employ any personiin such manner as to become subject to workman's compensation laws of California." Conyacto�hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, l shall employ per;s subject to workman's compensa- <br /> i tion laws of California." l <br /> N <br /> The applica ust call for a required inspections. Complete drawing on�re'v�erse side. <br /> r <br /> Title: <br /> Signed X Date <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> p Date ; '} Area <br /> Application Accepted by i <br /> �'+ l at Final Inspection by Date <br /> f�iiNor Grout Inspection by� l <br /> Additional Comments: F <br /> ❑ 5tk 466-6"11-4—D� -odi__3693621—W-- 4C l-Manteca�823 7134 -B T cy--835=6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 85201 <br /> RECEIVED BY DATE PERMIT NO. <br /> 'r IEEE AMOUNT DUE AMDUNT.REMITTED CASH <br /> +.EH 1324(REV.I/B 5) <br /> EH 14-28 <br />