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TIO 0 ERMIT <br /> i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.'HAZEL TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED :a <br /> � - P3 <br /> (Complete in Triplicate) escribed. This application is <br /> alth District for a t to construct <br /> Application is hereby made to the San Joaquin L Hance No.549 for sewage or 1and/or <br /> He No . 1862 for welllpump and the Rules and hereinR Regulations of he San Joaquin <br /> made in compliance with San Joaquin County <br /> Local Health District. --, PM <br /> M P Lot Size <br /> � City <br /> I <br /> Jobe/Address S- / <br /> t-71!, <br /> Phone--S Address <br /> Owner's Name <br /> !� 577 License No. 4O� Phone <br /> i Contractor )©1 ens Address <br /> ❑ WELL DESTRUCTION ❑ <br /> WELL L REPLACEMENT Li! TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE <br /> r� <br /> DISTANCE TO NEAREST: SEPTIC TANK —.� SEWER LINES PITSISUMPS <br /> OTHER WELL t h <br /> FOUNDATION —�- <br /> 7-AGRICULTURE WELL v 1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> Dia, of Well Excavation <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Specifications <br /> ❑ Gravel Pack ❑ Tracy Type of Casing <br /> ❑ Domestic/Private Type of Grout I 1 <br /> 11 ❑ Other Depth of Grout Seal - <br /> k 11 Public 1 fl Delta Surface Seal installed by <br /> --Approx. Depth I I Eastern } <br /> I l Irrigation H P State Work Done — <br /> Repair.Work Done e,D Type of Pump �-- } �} <br /> Sealing Material (top 50'1 <br /> Well Destruction ❑ 1Ne11 Diameter _--.-- Filter Material (Below 50'M <br /> f Depth <br /> G TYPE OF SEPTIC WORK:` NEW INSTALLATION I <br /> I`: ION I I DESTRUCTION I Iavlailabpe�withina200 feet�tted if pu4sewerilsInstallation will serve:A Residence_X 'CommercialOtherNumber of living units;' Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 teat: 6? No?Compartments <br /> MI <br /> SEPTIC TANK ❑ TypeIMfg �— Capacity <br /> Method of D�p4�I <br /> r PKG. TR£ATMENT'PLT. ❑ !f/ <br /> Y—Foundation Pro ert Line <br /> �..; Distance to nearest: Well 1__. - Foundation P Y <br /> Total length/size <br /> LEACHING LINE f" {No. & Length of lines -- <br /> FILTER BED 4. ❑ YDietance'to nearest" "Well �rQ Foundation Property Line _ " <br /> SEEPAGE PITS I Dea pth Size *3 Number <br /> SUMPS L-1Distanceto nearest: -FouZiatidn "- Property Line_ r <br /> DISPOSAL PONDS ❑ `-;� <br /> l I hereby certify that I have prepare d•this"'dpplication and that the work will be done in a dc ordance with San Joaquin county ordinances, state laws, ands- <br /> rules and regulations of the San Joaquin.Local Health Di?atrict. <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 /> /ta employ any person in such manner as to-become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> it certifies the following:"I certify that in the performance of the work for which this permit is issued,i shall employ,peisons subject to workman's compensa- <br /> ' tion laws of Calif ia." �'`—�,tea <br /> The applicant m 's call for all quired ins cti . Comte ing on reverse side. ^• ! rr ` s <br /> F < - <br /> Signed itle: Date <br /> +�. <br /> FOR DEPARTMENT USE ONLY y' 4 <br /> Date Area <br /> Application Accepted by --- � <br /> Pit or Grout Inspection by - date Final inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 , <br /> j Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE f ERM1T'NO. <br /> INFO (�G <br /> UQ t <br /> +.FH 13-21 1REV.r/x 51 � <br /> EH t4-28 <br />