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tr <br /> y1fy��_ APPLICATION FOR PERMIT f <br /> SAN JOAQUIN'LOCAL HEALTH DISTRICT <br /> :y <br /> F 1601 E. HAZELTON AVE., STOCKTON, CA ; <br /> Telephone (209) 466-6781 <br /> i r , <br /> PERMIT EXPIRES'1'YEAR FROM DATE 'ISSUED' ' ` � "'` s� 'ra ;rlti <br /> (Complete_in Triplicatef , , f �, <br /> s.ry:- ?> 1ti ,wR �� � Ila�t'.-. -"�...,'-'.�l.6t"iq - -, iv s.„ -.. .,.��E s -,"s r� � r•.� 9 ,,. }��- +. + ' <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 R41es and Regulations of the San Joaquin <br /> Local Health District. `3{< ! y' --- (yy� z 3 ks3 j <br /> p•' •F�e' -� :�iV �• :r�q. 4 Eit..i -~ry - � 'Ls ! '�(i_ - f_ - i4�' <br /> Joh Address Z ;°'/.70; /� aVsa' t. .' ` r; City 1`4sjeyTeGA tLot 51ie �lcres PM <br /> .'"I C4. s .ala <br /> r E <br /> Owner's Name-- �I /hb N X-d 1 N Wl'-t SO*. —Address: -yAAe .:,.ii,_ Phone <br /> r•, <br /> Contractor Y_� -sem -�ry Address., "'•B���l�e T "T1=icense'No:'�/ '$�� Pf tine <br /> TYPE OF WELL/PUMP: NEW WELL ❑` WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION E SYSTEM REPAIR,E] - OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEMARE . CONSTRUCTION SPECIFICATIONS <br /> ElIndustrial ElOpen Bottom ❑ Manteca Dia.of'Well Excavation Dia. of Well Casing 1 <br /> I <br /> ❑ Dc rustic/Private El Gravel Pack.. .C:Tracy Type of Casing Specifications <br /> F] Public ❑ Other ❑1Delta Depth of Grout Seal Type of Grout <br /> D'Irrigation --Approx. Depth ❑,Eastern Surface Seal Installed by <br /> RepairWork Done ElType of Pump H.P. State Work Done <br /> t <br /> Well De struction ElWell Diameter: Sealing Material (top-501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 10` REPAIR/ADDITION ❑ DESTRUCTION„❑R{Mo,.septic system permitted if public sewer is <br /> c 1` vavailatile,within 200 feet.) <br /> Installation will serve: Residences Commercial_ Other �i6 lir��e <br /> Number of living units:--I_ Number of bedrooms <br /> Character of soil to a depth of 3 feet: :Water table depth <br /> COAec. P� CAsT Capacity SEPTIC TANK zX <br /> TypelMfg ty �d�� No. Compartments <br /> PKG. TREATMENT PLT. ❑ V` Method of Disposal , <br /> Distance to•nearest: Well # Foundation �� Property Line -�S <br /> LEACHING LINE Xr No.-& L��e--n��g--t��h of lines" r W Totall n th/size 6 a f [ <br /> FILTER BED ❑ tbistance';totnearest: Well a1�' Foundation /o Ord-rtVLine <br /> SEEPAGE PITS ° ❑ 'Depth ' ' - -Size ' ' Number S! '� <br /> SUMPS Distance to nearest: Well 6S Foundation /� Pro rty Line. y ea <br /> DISPOSAL PONDS ❑ _I_ t j <br /> I hereby certify that 1 have prepared this applicationand°that"the-work wilt-lye done in accordance with'San-Josquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local'Health District. ` aw- f <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the parformaitce of thetwork 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."Contractor's hiring or sub-contracting signature . <br /> certifies the following:"I cartify 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 applicant must all for all required inm <br /> specti ns. Complete drawing on reverse side. <br /> f <br /> Signed V Title: `° I Date: <br /> . �. �_-1D1_E­P_ARf_FM ENT USE�ONLY�t <br /> Application'Accepted by, 4F <br /> _ 'Date Area <br /> i w ,�6 pet- <br /> J <br /> Pit or Grout Inspection by Date '' Final Inspection by. Date <br /> Additional Comments: Y <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 . _ ❑ Tracy 8356385 "N+f _ <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave:, P.O. Box 2009,;Stk., CA 95201 <br /> 4CK <br /> FEEAMOUNT DUE. AMOUNT-REMITTED - CASH , RECEIVED BYE. . . _DATE PERMIT'N0. <br /> ;INFO <br /> E1d 13-24{REV.t <br /> EH 14-26 - .• F <br />