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J <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> i 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 he described.This application is <br /> made in compliance with San, oaquin County Ordinance No.549 for sewage or No. '862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address —. T i•d �f-- <br /> City —&ALVot Size PM <br /> i <br /> Owner's Name 2- Address b /� go phD�rle 7- � <br /> I� j 5 � �1. <br /> Contractor_ - _ _ °C /_t�. �. dress �- .a ' _/4f � <br /> I L-icense�No <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER'LINES�"7 �"- - <br /> .I � DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL. + 'OTHER WELL PITS/SUMPS _ <br /> i. INTENDED USE <br /> _T.ff PE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial - f ,r <br /> ❑ Open Bottom ❑ Manteca Dra. of Well Excavation <br /> i' Dia.'of.Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy f -,Type of Casing's" <br /> Specifications <br /> Q Public <br /> ❑ Other ❑ Delta Depth of Grout Seal <br /> ❑ IrrigationI_MJq Type of Grout <br /> pprox. Depth ❑ Eastern Surface Seal Installed by ; <br /> Repair Work Done ❑ Ty. of Pump H.P. t_. <br /> State Work Done <br /> Well Destruction ❑ "Well Diameter Sealing Material (top 50') t * "E <br /> Depth Filler Material {Below 5011 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION K REPAIR/ADDITION ❑ DESTRUCTION.O.(4No septic system <br /> I�..permitted if public sewer is <br /> available within 200 feet.) J <br /> Installation will serve: Residence R Commercial i Other <br /> Number of living units: Number of bedrooms +•f ` p <br /> Character of soil to a de`P th'af 3 feet: S <br /> F" Water table depth r <br /> SEPTIC TANK xa Type/Mfg'', ) <br /> Capacity�_a_ d 0 No. Compartments <br /> PKG. TREATMENT PLT. ❑ �I <br /> f 1 Method of.Disposal <br /> Distance to nearest: Well s v <br /> Foundation <br /> Property Line �.Q <br /> LEACHING LINE rxf No. & Length of lines <br /> -_ • <br /> FILTER BED y Total length/size' ' f <br /> ❑ Distance to nearest: Well Foundation' �♦ Property line I <br /> .—L-J' <br /> SEEPAGE PITS ❑ Dlepth Size ` <br /> Number` <br /> SUMPS C7 It to nearest: Well "� -'" <br /> illi tion Property Line <br /> DISPOSAL PONDS ❑ I Foundai <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 Sar'Joaquiri Local HealtFi'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 r <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. <br /> certifies the following: "I certify that in the performance of the work for which this <br /> tion laws of Cal ornia" I�. ,"_ .. per <br /> Tit is issued, I shall empicy/persons subject to workman's comperisa- <br /> The applic st l for.all r I�quired inspections. Complete drawing on reverse side. <br /> Signed r a Title: N <br /> l Date: <br /> ' <br /> FOR ARTMENT1USE ONLY% 1 <br /> 3 <br /> Application Accepted by � � <br /> 7 J3 <br /> Date Area <br /> Pit or Grout Inspection by; Datef <br /> Final Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 O Lodi d 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6386 <br /> Applicant- Return all copies to:I'IlEnvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> q <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED <br /> CASH RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24{REV.I/B 5) <br /> EH 14.28 !I� ! � �. `�(� �Q� �^" �2la <br />