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it <br /> I� <br /> ' APPLICATION FOR PERMIT <br /> SAN 16AQUIN LOCAL HEALTH DISTRICT <br /> ! 1601 E. N Z�EL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> i I PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> describea.This <br /> cation <br /> cationis <br /> Application is hereby made the S nnCounty Ordinance Nto. 549 for sewage or INo. 1862 forcweli/dpump and the Rules and Regulations of the San l Joaquin <br /> Joaquin Local Healh District for a permt to construt an /or install the work herein <br /> made incompliance with Sann the <br /> ry <br /> Local Health District. <br /> ib �Tn�� Z r City Lot Size v x PM <br /> Job Address <br /> Address J64hone 3 I Z- <br /> Owner' Name Z� <br /> } � G � <br /> Contra�tor �� Address, �� - L-icense N Phone <br /> TYPE OF WELL/PUMP:'; NEW WELL Ld�V -mWELG REPLACENIEfJT4❑' "' DESTRUCTION ❑ <br /> i 1. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INT:;ENDED USE TYPE OF WEL°L�'"a""PR09LEM=AREA" CONSTRUC710N'SPECIFICATIONS <br /> ❑ Industrial 17Open Bottom-, <br /> O ManIf <br /> caDia. bf EWE�xcavati Dia. of Well Casing <br /> ❑ pomestic/Private q�Gra�el.'Pack ❑ Tracy Type ofVCasing Ilk <br /> # Specifications <br /> ' v #� ❑ Delia" Depth of IG rout Seal Type of`Grout,a- <br /> [1 Public � l=1 Other r �... <br /> k <br /> I Irrigation --Approx. Depth l 1 Eastern Surface�Sealjlr�stalled by } <br /> f P ".+rw aru IRH P *' r • State ork Done <br /> Repair Work Done ❑ Type of Pump xi �, o- <br /> i Well Destruction -11VeODiameter" "� ' Stealing �ateria#`Itok 50'] <br /> tyk Depth' I Filler Material (Below 50'} _ t <br /> TYPE"OF SEPTIC'`WORK's NEW INSTALLATION l REPAIRIADDITION l It !DESTRUCTION l i (Ngseptic system permitted if public sewer is {� <br /> I r `� available within 200 feet.) <br /> Installation will serve: Residence Commercial 4 Other If i <br /> ll - <br /> Number of living units: _J_ Number of b Brooms _ — e <br /> Or <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ITypeLMf - - �.� s Capacity Z� o. Compartments Z <br /> g3 <br /> PKG. TREATMENT P,LT �` �� .16 %' 4 Method of Dispo�afi <br /> 1 RRR, . <br /> Distance to nearest: Wek1l -�- Foundation Ifooertv Line <br /> ( <br /> d[' <br /> LEACHING LINE ❑ No. & Length of lines To al length size �. <br /> I ' io P _ <br /> r <br /> FILTER' BED ❑ Distance to nearest: Well_100T Foundation, Pro arty Line <br /> SEEPAGE PITS l 1 Depth size -� <br /> "�'�" N mbar <br /> SUMPS Ll Distance to nears l WelFoundationwo Property Line <br /> DISPOSAL PONDS ❑ 1--ft I1 <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 /> j employ any person in such manner as to become subject to workman's compensation laws of CaliforAia Contractors hiring or sub-contracting signature <br /> fk certifies the following: 1 certify that in the performance of the work for which this permit is issued, I shag employ persons subject to workman's compensa- <br /> tion laws of California." ` <br /> The applicant alust cal for II requir ins ctions. Complete drawing on reverse side. <br /> `" -/O <br /> Signe <br /> X Title: Date: - <br /> i OUSE ONLY <br /> Application Accepted by ate �%a Area <br /> ipate Final Inspection by Date <br /> Pit or Grout Inspection by <br /> i <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-MS <br /> Applicant - Return all copies to',Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> AMOUNT DUE AMOUNT REMITTED <br /> FEE CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> 1JR­ <br /> +'EH 13-24 M.V. /w 51 0 �,Q <br /> EH 14-26 M. <br />