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APPLICATION,FOR,PERMIT
<br /> SAN JOAQUIN;LOCAL,HEALTH DISTRICT
<br /> 1601 E..HAZELTON.AVE,, STOCKTON, CA
<br /> "Telephone (209) 466-6761
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<br /> PERMIT EXPIRES 1 Y.EAll3 FROM DATE ISSUED. ..
<br /> R-to;716rj�.a loue azq—,;..btncEycsa Pr,►lr,01r1l.a"I,IU .,,t (Complete in Triplicate) � .•ti ,. i1 w ,r ,. , �sY. € t 1
<br /> Application 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 />\ made in compliance With San Joaquin County,Ordinance No.,549 for'sewage or No.,1862 for,wall/pump:and the Rules and Regulations of the San Joaquin k
<br /> Local Health District. b.
<br /> .f /jtr, Ti G ' ti+tL/1{ '.SFj L, Y".+a TEs "3 a,:"' i s.wx+b s:.'. +",. 4 `i4.._
<br /> a Job Address 3} r, �J � rf.
<br /> S`3 . . .� E' . 1 T
<br /> City Lot Size _ PM
<br /> Owner's Name'sAddrens Phone
<br /> Contractor's Name �fft %a�I ' K �ei� cense N - Phone—
<br /> ( 70
<br /> TYPE
<br /> TYPE OF WELL/PUMP: NEW WELL Z WELL REPLACEMENT ❑ DESTRUCTION ❑ '
<br /> PUMP'INSTALLATION ❑ : r SYSTEM REPAIR"❑ 'OTHER ❑
<br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . DISPOSAL FLD.__ PROP. ,LINE
<br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS
<br /> V INTENDED USE TYPE OF WELL :PROBLEM AREA CONSTRUCTION SPECIFICATIONS
<br /> ffi Industria dT{7H Open Bottom ❑ Manteca Dia. of Well Excavation T` _` Dia. of Well Casing
<br /> ❑ Domestic/Private
<br /> s �yG "-
<br /> ® Gravel Pack ,!�Tracy ; Type of Casing �_ .p Specifications
<br /> s�
<br /> 1-1Public, ❑ Other El Delta } Depth of Grout Seal t' " Type of Grout __ �~-
<br /> ❑ Irrigation• - /,�gpprox.. Depth ,❑ Eastern Surface Seal Installed by X;f +
<br /> 'Repair Work Done ❑ Type of Pump H.P. State Work Done 'y
<br /> ,Well Destruction ',❑ + Well Diameter Sealing Material (top 50'1 n�a- Y+
<br /> s, I Depth Filler Material{Below 50')
<br /> TYPE OF*SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION❑ DESTRUCTION ❑ (No septic system permitted if public sewer is .
<br /> 'available within 200 feet.) �JV
<br /> Installation will serve: Residence_ Commercial Other
<br /> Number of living units: Number of bedrooms
<br /> -Character of soil to a de depth of 3 feet:' Water table depth-
<br /> SEPTIC
<br /> epthSEPTIC TANK 1❑ iType/Mfg Capacity---J-- 'No. Compartments
<br /> PKG. TREATMENT PLT.❑ !1.` 4'
<br /> `'� Method of Disposal � !
<br /> " -Distance to nearest: Well" rt` Foundation Property Line
<br /> tEACHING LINE i ❑ FNo. & Length of lines t Total length/size
<br /> F FILTER-BED '❑ 'Distance to'nearest: ',Well, Foundation Property Line �}
<br /> SEEPAGE PITS ❑ !Depth rya "" Size Number
<br /> - SUMPS ❑ -`Distance to nearest:' Well' Foundation Property Line ,
<br /> DISPOSAL PONDS .--._+ El_
<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. . . '
<br /> Home owner or licensed agent's signature certifies the following:i'I 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 become subject-to workman's compensation laws of California." Contractor's hiring or sub-contracting signature a ?
<br /> certifies the 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 /> I The applicant must call for all required inspections. Complete drawing'on reverse side. IIj
<br /> i Signed X Title: d/i ?
<br /> Date:
<br /> ! i 1 j
<br /> FOR DEPARTMENT USE ONLY i 74r
<br /> A
<br /> plica 10 Acce ted b ; ! 2 17
<br /> I pp p y pate k Areae .
<br /> - 4-- _
<br /> I :Prt or Grout Inspection by e Y':� i Date ��-�� Final Inspection by ` t°Date h
<br /> Additional Comments: I
<br /> - ❑ Stk -46$-6781- ❑ L-odi.. 369-3621'-' -D-Manteca 823-7104 ❑Tracy 835-6385 4
<br /> j Applicant,- Return all copies td¢ Environmental Health Permit/Services 1601.E..Hazelton Ave.t,P.O. Box 200A, Stk.,CA 95201
<br /> ,ice�.__ �, {: --
<br /> ~
<br /> INFOFEE IAMOUNTDUE AMOUNT REMITTED CASH RECEIVED DATE PERMIT`NO.
<br /> t
<br /> r+EHI&W(REY 01931
<br /> EH 14-25
<br /> r
<br />
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