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APPLICATION.FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL TO N AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 ' <br /> r... e . r ,— '-9 <br /> PERMIT EXPIRES !.YEAR FROM DATE ISSIJiD' <br /> o <br /> (Complete in Tripkate) ,.t 61, .. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein'deicribed.This his a-p'pliciaiii6n 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., <br /> 1141 nf ln4n <br /> Job Address — City Lot Size-::Z EJ -PM <br /> Owner's Name Phone <br /> Contractor's Name 'f/?6OA17Add— <br /> 'License No. 60- Phone <br /> TYPE OF..WELL/PUMP: NEW WELL 13 WELL REPLACEMENT El DESTRUCTION 11 <br /> - i N j-PUMP7INSTA-CaTION-El SYSTEM-REPAIR-E] OTHER-E] <br /> DISTANCE TO NEAREST: SEPTIC' TANK SEWER F1—INff----7-----DISPOSAt-FLD.- PROP. LINE <br /> FOUNDATION AGRICULTURE WELL: OTHER WELL PETS/SUMPS <br /> INTENDED USE TYPE,OF WELL PROBLEM.' <br /> 'AREA CONSTRUCTION SPECIFICAT16NS ' <br /> 1-1 Industrial El Open-Boiko ml .-I 0 Manteca Dia:of Well7txc'a3ati&hl' Dia. of Well'Casing <br /> El Domestic/Private 0 Gre'vel'Pack n.,# 1 .0 Tracy Type of CasingSpecifications <br /> El Public I El Other, SCJ Delta Depth of Grout Seal type of Grout <br /> El Irrigation Depth"" Eastern, S6rface Seal Installed by <br /> Work Done El Type of Pump H.P. State W6rk Done <br /> N .4 . . -S <br /> Well Destruction [I Well Diameter Sealing Material itop 501 <br /> Y., 0- A�c <br /> Depth ..,,.,vFiIIer Material wreqw <br /> P <br /> TYPE OF SEPTIC WORK: NEW.INSTALLATION 0 'REPAIR/AI)DlTtONPC:;L!ES-T-RUC-TION-P-(N6 septic system�permitted if public sewer is <br /> iN A available within 200 feet.) <br /> Installation will serve: !Residence .f Commercial N? Other <br /> Number of living unlis:il­ Number,of bedrooms <br /> Character of soil to a depth of 3 fe,et: Water table depth <br /> - #.'- e- *1 t4l,% 4 <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 13 Method of Disposal <br /> Distance to nearest: ell,-- Foundation Property Line <br /> T <br /> LEACHING LINE :0 No. & Length ofli6,N- Total length/size-il� <br /> FILTER BED El Distance to nearest *"V16`11 "'Foundation Property Line <br /> 0 <br /> SEEPAGE PITS El Depth f _ Size ber <br /> SUMPS rest; Well AQ�M�ff:o',Jation-k Prop Line <br /> 9 Distance to nearest: A A Ty 57 <br /> DISPOSAL PONDS F-1 %; <br /> I hereby certify that I have prepared this application and that the work-will be done-in"i-cc-6rdance--w-5-h-S-a 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:ollowing: "I certify that ini the peh6rmance of the work for which this peirmit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws-of California."Contractors hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance-of the work for which this permit is issued,I shall employ p6rsons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant stC,all for all required inspections. Complete drawing on reverse ide. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> R5 <br /> Application Accepted by Date Area <br /> Final Inspectic' <br /> Pit or Grout Inspection by Date in by Data <br /> Additional Comrn'ents%- <br /> 0 Stk 466-6781 0 Lodi 369-3621 1!rMantecgCSWR� '4 11 Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA SMI <br /> FEE AMOUNT DUE ­AMOUNT REMITTED CK RECEIVED BY DATE.— <br /> INFO CASH PERMIT'!NO.' <br /> 00 <br /> + EH 13-24 IREV.10/83) <br /> I <br /> EH W26 % <br />