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t <br /> f <br /> APPLICATION FOR PERMIT <br /> 4vo SAN JOAD.UIN LOCAL HEALTH DISTRICT I <br /> 1601 E. HAZE T ON AVE.,-STOCKTON, CA <br /> Telephone (209).466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE.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.. a, _ <br /> ty rttl' r 'rr �'p1 f1AIiw 211 <br /> Job Address �. � 7] City 91 Lot Size- PM <br /> Owner's Name .�idN ^Address Si�i»� - - Phone <br /> Contractor�g&%%h i SOMI Address?.0. eox A&M License No2Ar9ff43 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑-- DESTRUCTION ❑ <br /> ' L..,r M. <br /> UMP1N5T4CL4T -^"'10N " """SYSrtEI�A"REPA1 '❑ OTHi❑ <br /> DISTANCE T.0 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> t i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Openj'oo'tt6rr4 ❑ Manteca Dia- of Well Excavation i Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing i Specifications <br /> ❑ Public „; ❑ Other ❑ Delta Depth of Grout Seal r ' I Type of Grout <br /> a <br /> LJ Irrigation ---Approx. Depth ` ❑ Eastern .._,. ,.Surface-Seal-Jnstalled,4 i'0 <br /> Repair Work Done ❑ Type of Pump n H.P. State,Work Done <br /> Well Destruction ❑ Well Diameter '✓ Sealing Material (top 50') j I <br /> Depth i Filler Material (Below:50'1' l ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR'/ADDITION ■ DESTRUCTION ■'(Nolseptic system permitted if public sewer is <br /> a- available within 200 feet.) <br /> Installation will serve: Residence� Commercial_ Other_ f <br /> Number of living units:--(777--Nu' <br /> __ Number of bedrooms <br /> Character of soil to a dep¢fs�f 3 feet" iJ L ; <br /> i Water table depth <br /> n l.. <br /> "SEPTIC TANK 'S Type/Mfg Capacity /.2_ _9A2__ No. Compartments OZ <br /> PKG. TREATMENT PLS❑'l +u�� jr1 `� �`'+. Method of Disposallo <br /> 1A Distance to nearest: Well S'O Foundation, IXC Property Line.24� <br /> LEACHING LINE ❑ No. & Length of lines ��.t<;TotaElengih/size <br /> FILTER BED M Distance to nearest: Well -S�f'• Foundation .20. _x"[' Property Line _,2!67 <br /> SEEPAGE PITS `❑ lDepth Size Number <br /> SUMPS +❑ .,Distance to nearest:• Well Foundation "' :Property Line �! <br /> DISPOSAL PONDS ••` .❑ rI'1 <br /> �.r 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 af,the work for which this permit is issued, I shall not <br /> °Z employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> ill 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." <br /> The appli t must call for all required inspections. Complete drawing on reverse side. <br /> Signed Title: Date: 0I-/(0- S& <br /> FOR DEPARTMENT USE ONLY <br /> i Application Accepted by T1 Date L f2 Area <br /> Pit or Grout Inspection by Date Final Inspection by I Date <br /> Additional Comments: 14" W4 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ hfanteca 823-7104 it Tracy- 835"5 - <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE 1 INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMITNO. . <br /> + EH 13-24(pEV.r/85) <br /> EH,14-28 - O - <br />