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? � APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone {209} 466-6781 <br /> PERMIT EXPIRES 7 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 herein described. This application <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for w 11 PP attan is <br /> Local Health District.�, e /pump and the Rules and Regulations of the San Joaquin ! <br /> J Address � <br /> City Lot Size PM <br /> wner's Name ` 4 <br /> Address o� .0 6!i� Q <br /> C, Phone <br /> Contractor Address <br /> License_ No, ��. Phone <br /> TYPE OF WELL/PUMP: NE WELL ElWELL REPLACEMENT ❑ <br /> DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ OTHER ❑ tj <br /> - SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK S R LINES <br /> (DISPOSAL FLD. PROP. LINE <br /> 1 FOUNDATION { AGRi ULTURW E i <br /> !OTHER WELL PITS/SUMPS <br /> t <br /> • INTENDED USE � "f"'e� ' <br /> TYPE OF WELL' j PROBLEM ARE NSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca <br /> >, t_ _ _Dia:of-Well_Excavation Dia. of Well Casing❑ Domestic/Private ❑ Gravel'Packµ '4[] Tracy ype of Casin _ ¢ 9 <br /> ❑ Public ❑ Other % ❑ DelSpecifications <br /> De th of Grout Sea%F, <br /> ❑ Irrigation Type of Grout <br /> ---Approx. pepth astern Surface Seal Installed by I i <br /> Repair Work Done ❑ Type of Pump H.P. , <br /> State Work Done t r <br /> Well Destruction ❑ Well Diameter # <br /> Sealing Material (top 50') <br /> Depth Filler Material lBelow 50'1j f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Installation will serve Residence` Commercial_ Others av 'lalile within 200 feet.) I <br /> GGG�;6l�fCL "`KCKK. 4. <br /> rr <br /> Number of living units: Number of bedrooms E. / <br /> Character of soil to aidepth of 3 feet: 1 <br /> SEPTIC TANK Water table depth <br /> L1 Type/Mfg i <br /> PKG. TREATMENT PLT. L1t Capacity T No. Compartments <br /> Method of Disposal <br /> Distance to nearest: Well Foundation <br /> r <br /> Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED E <br /> ❑ Distance to nearest: Well -Foundationf <br /> Property Line <br /> SEEPAGE PITS a <br /> ❑ Depth Size Numbei <br /> SUMPS ❑ Distance to nearest:. WeltFoundation 'DISPOSAL PONDS 12Property Line--_- Av <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 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'becoiine subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the followingV <br /> :"!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." t '�-� � _ <br /> The applican ust call for all r ired inspections Complete drawing on reverse side. <br /> Signed X { � <br /> Title Date: q <br /> t <br /> FOR DEPARTMENT USE ONLY ' <br /> - r k <br /> Application Accepted by Area <br /> Date <br /> �0 <br /> a y 11—Pit or Grout Inspection by DateP y fl <br /> ;Final Inspection b Date <br /> Additional Comments: ' �{{r� <br /> Q Stk 466.6781 �O"Lodi 369-362 "' (E-Manteca 823-7104 <br /> ❑ Tracy 635-6385 � <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,Stk., CA 95201 <br /> \ i <br /> FEE gMgUNT4'DUEs CK Cl\ <br /> lNFO t AMOUNT REMITTED CASH RECEIVED BY DATE' PERMIT'NO. <br /> 3' <br /> + EH 13-24(REV.tin5y <br /> EH 1428 .. - 41 <br />