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APPLICATION_FOR.PERMIT <br /> ­­ . .k, <br /> SAN JOAQUIN,LOCALHEALTH DISTRICT <br /> 1601 E. HAZELT-ON-AVE., STOCKTON, CA <br /> Tfielepon' e (20466-6781- <br /> PERMIT EXPIRES 1 YEAR FROM DATE.'ISSUED <br /> a"; oto,(Cpmplete in 7riplicate); F, <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 is <br /> made in compliance With San JoaqUin County,Ordinanoe No:649 for sewage or No.1862 for well/.pump and the Rules and Regulations of the San Joaquin <br /> Local Health District.. VIE 10 <br /> PM <br /> Job Address City_, 4414iMiz�t size <br /> " .. .1 - -­ - I 6"A 141r <br /> Name Addr ress 4fo" 44qW hone <br /> Owner's <br /> Contractor's <br /> License No. Phone <br /> NameA <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 ?OTHER E3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. 'DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELLPITS/SUMPS <br /> INTENDED USE TYPE OF WELL TPROBLEMAREA CONSTRUCTION SPECIFICATIONS <br /> :0 Industrial El Open Bottom- 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 0 Domestic/Private 0 Gravel Pack b Tracy Type of Casing Specifications <br /> 0 Public 0 Other 0 Delta Depth of Grout Seal Type of Grout Il <br /> El Irrigation �Approx.­Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done El Type of Pump H.P. State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 601 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION'VL, REPAIR/ADDITION 13 DESTRUCTION El (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence,k Com.makial Other' <br /> Number of living units:. Z Number of bedrooms a= <br /> Character of soil to a depth of 3 feet: SCAVYM4 0 X -Water table depth <br /> SEPTIC TANK El Type/Mfg Capacity 99 SM No. Compartments �7 <br /> PKG. TREATMENT PLT. 0 . Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines L 0 Total length/size <br /> FILTER BED ;E1 Distance to nearest: i Well I ft4 Foundation S Property Line <br /> SEEPAGE PITS 0 Depth Size f Number <br /> SUMPS -0 Distance to nearest: Well -Foundation,.­ J Property Line <br /> DISPOSAL PONDS El <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 Son 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.become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following:"I 6ertify 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." <br /> The apRPeanwoust pall forinspections,,,Pomplete drawing on ran <br /> ,Signed X =`tle- Date: L�_ <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date rea <br /> Pit or Grout Inspection by Date Final Inspection b Date tx <br /> Additional Comments; <br /> 0 Stk 46643781.- - - 0 Lodi 389-3!1 l 0 Manteca 823-7104 CI Tracy 835-6385 <br /> Applicant- Return 611 copies to-. Environment6i Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE P.ERMn"NO. <br /> INFO CASH <br /> EM 13-24(REV.10/x31 -7 <br /> EH W20 <br />