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0 <br /> APPLICATION FO,R,.PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 2 <br /> PERMIT EXPIRES 1 YEAR FROM OATE",ISSUED.,, <br /> (Complete in Triplicate) <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 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 /> W14 <br /> Job Address City Lot Size <br /> Owner's Name dv%*17_f4 AfoTeer Se" Address Phone <br /> A - <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT-.0 DESTRUCTiOWD- <br /> 'Y" <br /> PUMP INSTALLATION L SYSTEM REPAIR 0 OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — DISPOSAL FLO. rPROP: LINE <br /> FOUNDATION. AGRICULTURE WELL — OTHER WELL PIMSUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial E Open Bottom 0 Manteca Dia. of Well Excavation C.a§png_. <br /> 0 Domestic/Private Ll Gravel Pack El Tracy Tye of Casing Specifications <br /> 0 Public 17 Other El Del Depth of Grout Seal Type of Grout <br /> —P U'r <br /> 0 Irrigation _-Approx. Depth El Eastern Surface Seal Installed byj 11�/ <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction 0 Well Diameter -------L--> Sealing Material (top 50') <br /> Depth Filler Material (BeI2!50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 171. 'REPAIR/ADDITION DESTRUCTION 13 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units:— Number of bedrooms It I <br /> Character of soil to a depth of 3 tal depth <br /> SEPTIC TANK 0 Typo/Mfg' Capacity N61-Com- pprtments- <br /> PKG. TREATMENT PLT. ❑EI <br /> j Method of Disposal <br /> Distance to nearest: Well Foundation Pr9perty Line <br /> ..LEACHING LINE �FIo, & Length of lines A'7_11 Total length/size <br /> !FILTER BED C Distance to nearest: Well f!7_54.9- Foundation 7 D Property Lin'el_r.. <br /> wb 7 <br /> SEEPAGE PITS Ae--Depth _Size 3 Number 1Z <br /> SUMPS 0 Distance to nearest:"' ,Well Foundation U Property Line <br /> DISPOSAL PONDS Li <br /> I hereby certify that I have prepared this applic6ti3nand that1he work will be done in accordance with San Joaquin coL;nijPbrdinances;Qs-iate laws, and <br /> rules and regulations of the San Joaquin LocaF`ke4fth Distrito. -2" 1 <br /> Home owner or licensed agent's signature certifies the f'ollowing: "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 workmali'Tcdmbensation laws of California."Contractor's 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 employp6rsons subject to workman's compensa- <br /> tion laws of California." <br /> 0�1 <br /> The applicant 11 r fired itOktions. Complete'drawing on.reverse side <br /> Signe X Date: <br /> -FOR-DEPARTMENT USE-ONLY <br /> Application Accepted b Date Area 021 Ze <br /> Pit or Grout Inspection by Date Final In ction bv Date <br /> Additional Comments: 01 bl'i - kk&e,' <br /> ff XS!k 466-6781 D Lodi 36d-3621 ❑ Manteca 823-71D4 0 Tracy 835-6385 <br /> S <br /> Aplicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE C <br /> AMOUNT DUE AMOUNT REMITTED K 0 <br /> ' <br /> NFO. CASH RECEIVED BY DATE PERMIT`NO. <br /> +EH 1324 MEV.101831 V <br /> EM 1428 4C <br />