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APPLICATION FOR PERMIT PAY M 9 N <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT RFEC-SIVED <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-Ml AUG <br /> PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED tNVIR07NMENTAL WEALTH <br /> (Complete in Triplicate) PERMITISERVICES10, <br /> 'Application is he-reby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This m application is-, <br /> made in compliance with San Joaquin,County ordinance No.M9 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District.'. , k;� . C <br /> Job Address 2 02— Ch, 60,,�k Lot Size PM <br /> .-Owner's Name J Address 7 2 ?,Q 2 Phone <br /> Contractor J Address License <br /> No. <br /> Phone <br /> V NEW WELL 0' WELL REPLACEMENF—X DESTRUCTION 0 <br /> TYPE OF WE=LL/PUMP: <br /> PUMP INSTALLATION 0 SYSTEM REPAIR C1 OTHER El <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> _4M SEWER LINES — DISPOSAL FLO. IM 44- PROP. LINE <br /> FOUNDATION AGRICULTURE WELLOTHER WELL �"Z - _PFT—S/SUMPS, <br /> — <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> E Industrial El Open Bottom, E3 Manteca Dia. of Well ExcavationDia. of Well Casing <br /> X Domestic/Private Gravel Pack 0 Tracy Type of Casing <br /> Ll Public ep Specifications <br /> El Other 0 Delta Depth of Grout SIZZ—V ��yp e o f�Gu t__1 A*�A�t )� 2 <br /> n Surface Seal Instal I <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> IJ Irrigation --Approx. Depth El Easter' tl <br /> Installed by <br /> Well Destruction 171 Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below Sly? <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDIT[ON 0 DESTRUCTION I-] (No septic system permitted if public sewer is <br /> I . 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: <br /> 6 _Water table depth <br /> SEPTIC TANK C Type/Mfg Capacity----------: No. Compartments <br /> PKG. TREATMENT PLT. 71 <br /> Method of Disposal <br /> Distance to nearest: Well Foundation <br /> Property Line <br /> LEACHING LINE 17 No. & Length of lines Total length/size <br /> FILTER BED 7-1 Distance to nearest- Well Foundation_ Property Line <br /> SEEPAGE PITS 0 Depth Size Number <br /> SUMPS [D Distance to nearest: Well Foundation <br /> Property-Line—_�_�—— <br /> ff <br /> DISPOSAL PONDS 11 <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 San 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."Contractor's hiring or sub-contracting signature <br /> tion laws of California." <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 /> The appligant st call for all req d inspections. Complete drawingn side, <br /> rave <br /> Date: <br /> T USE <br /> 0 Ly <br /> 4. <br /> R IVIIENT E <br /> Signed Title. <br /> r FOR 6E <br /> Application Accepted by Date Area <br /> at, <br /> Pit or Grout Inspection by at, Final Inspection by <br /> Date <br /> Additional Comments: <br /> D Stk 466-6781 0 Lodi 369-3621 ED Manteca 823-7104 0 Tracy 83546363,5 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE ' AMOUNT DUE AMOUNT REMITTED CK* <br /> NFO —CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24 1 REV.1/8 5) <br /> .EH W26 <br />