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APPLICATION FOR PERMIT .� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �f S <br /> 1601 E. HAZELTON AVE.; STOCKTON, CA 1 n <br /> I <br /> Telephone (209) 466-6781 1 Cho <br /> Gd 7 td PERMIT EXPIRES i YEAR,FROM DATE ISSUED <br /> /+C `1 <br /> vj' f �►�� (Complete in Triplicate) I <br /> Application is herebym>4de to he_la Jda <br /> quip Local Health District fora 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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District.. I �,. <br /> t <br /> Job Address �..� b City 611�� Lot Size 2501-fl10PM i <br /> O <br /> Address Name POe!0a . AQ(S _ Phone <br /> l <br /> Contractor c FAddre-ts r r-0. p— License,No. '!7J._ 1__,phone y S� <br /> TYPE OF WELL/PUMP: """""`"'-�f� �?y��("'❑ -r-- Wq R 0iei CEKAlENT-❑r�.w-DESTRU TION-0-` <br /> -, _.__ .­_t ..x- ._ .. <br /> i PUMP INSTALLATION 10 SYSTEM REPAIR ❑ <br /> DISTANC9 TO NEAREST: SEPTIC TANK SEWER LINES DISPO D. PROP. LINE <br /> I FOUNDATION ! AGRICULTURE WELL HER WELL PITS/SUMPS <br /> INTENbED USE TYPE OF WELL PROBLEM AREA C CTION SPECIFICATIONS <br /> ❑ <br /> Industrial ❑ Open Bottom 17 Manteca Dia. of Well Excavation Dia. of Well Casing r <br /> ❑ Domestic/Private El !ravel Pack : c <br /> 3 f y Type of Casing Specifications <br /> { <br /> ❑ Public ❑ Other It Delta _ Depth of Grout Seal Type of Grout <br /> ❑ Irrigation prox. Depth 2 EasXem _.Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work_ Done 1 <br /> I <br /> Well.De�sj ruction ❑ Welll Diameter Sealing Material (top 50') <br /> ( Depth Filler Material (Below 50') <br /> TYPE OyF�`SEPTIC WORK. NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic s <br /> p ystem permitted if public sewer is <br /> available wi hin 200 feet.) i <br /> Insta91�von will serve: Resi lence� Commercial Other <br /> ....Number of living units: Number of bedrooms ! 1 <br /> Cheracts r of soil to a dpth of 3q Wate:table depth i <br /> SEP'-IC Tr4NK Ty�pe/Mfg — Capacity\. Q No. Compartments r <br /> PKG:TR ATMENT PLT. k { a � Method of Disposal <br /> DistaAll"to neo t: Well Foundation Property Lint <br /> y <br /> i � d <br /> LEACHING LINE 'LlNo. & Length of line§ I Total length/size <br /> FILTER BED �❑ Distance to nearest: Well k Foundation Property Line i <br /> SEE,AGE PITS XDepth Size Number <br /> SUMPS O bistance to nearest: Weil Foundation Property Lire ; <br /> DISPOSAL PONDS I❑ <br /> I hereby certify that I h4 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. is { <br /> Home owner or licensed 8gent;';s signature certifies}he following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employany person in'such ma5ner as to become subject to workman's compensation laws of California."Contra'ctor's hiring or'sub-contracting signature <br /> certifies the following: "I certify that in the p_erforma'ce of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion'laws4of California." I " " -- - <br /> Tha appl"cant II for all�e red inspections. Complete drawing on reIlk 1 verse ide. j <br /> Signed II <br /> r # Title: Date' E7 <br /> I xI �� <br /> FOR DEP <br /> %RTMU.$E ONLY <br /> k i <br /> Application Accepted by, F . date l `a Arga <br /> f v J < i UJ I <br /> Pit or Grout Inspection 1 Date <br /> - _ Rnal Inspectior"by Date 64� <br /> Additional Comments: �_ �} � <br /> 1-1Stk 466-6781 ❑ Lod 3 T 1 "❑ Manteca <br /> Applicant Return all copies to; Environmental Health Permit/Serol 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO �^^ SFf RECEIVED BY DATE PERMIT NO. , <br /> + EH 1 -24IREV.5/x51 <br /> EH 1428 <br /> k <br />