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I a� <br /> E APPLICATION FOR PERMIT ® � D <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON ON AVE., STOCKTON, CA <br /> t Telephone (209) 466-6781 APR 2 19�g <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED Eivdii?Ji`:Av i'+ 1�'t_ E?C.'UrH <br /> (Complete in Triplicate) kRMii I SEWCES <br /> Application is hekeby 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 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 /> Job Address ___LA2WLot Size 2 .&OEJ PM <br /> Owner's Name A41VF7J" Address - �5`/�NIF_ Phone <br /> Contractor C�9.C/.U/4?FA �/+E-+ 4W641dress rise No.V42LZ Phoiie6q-7-7flif <br /> TYPE OF_WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK U� SEWER LINES —^ DISPOSAL FLDI_IW�CPROP. LINE <br /> FOUNDATION-•- - - - AGRICULTURE WELL - OTHER WELL PITS/SUMPS '�-.- <br /> INTENDED USE TYPE OF'eWELL PROBLEM AREA CONSTRUCTION SPECIFICAT ONS <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing <br /> DomeIA- stic/Private 19,11 Gravel`�Pack �y Type,of Casing P&- X10 . Specifications <br /> ❑ Public F, <br /> Depth of Grout Seal Type of Grout <br /> I I irrigation 16 ..Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ A,"Type of Pump H.P. State Work Done <br /> Well Destruction f� Well Diameter Sealing Material (top 50') <br /> Depth Filler Material.(.Below 50'), <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION_.I I REPAIWADDITION l 1 DESTRUCTION i I (No septic system permitted if public sewer is <br /> r 1 -1 -.-� available within 200 feet.) <br /> Installation will serve: Residence'— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> T <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> ' Distance to nearest: Well Foundation i Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to clearest: Well Foundation Property Line <br /> k <br /> SEEPAGE PITS l I Depth Size _ Number ` <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ - <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 taws, and <br /> rules and regulations of the San Joaquin Local Health DFItrict. <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 certify 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." I` _1 <br /> Tha applica mu t ca for all a ulred inspections- Complete drawing.on r rse side. <br /> Signed X .t <br /> Title: Date: <br /> ?. FOR EPARTMENT USE LY p <br /> Application Accepted by Date � O Area <br /> Pit_or Grout Inspection by DateFinal Inspection by Date <br /> c <br /> Additional Comments: <br /> ❑ Stk ;466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 1 <br /> FEE <br /> I <br /> i <br /> INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMIT'NO. <br /> t.EH 13-24(REV.(iris) <br /> EH 14.28 © <br />