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55j <br /> iR <br /> APPLICATION.,FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-678 1' <br /> W . PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED <br /> elf—, < (Complete in Triplicate). , <br /> 4 Application is hereby`made to the.San,Jo i3uir! obaI Health District for a permit to construct and/or install the work herein described.TMs application is <br /> made in compliance wrtfi San �o§�qum County O dinance No.549 for sewage or No.1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> LoW Health Die'tnc ` - <br /> r <br /> Jab Address 6; City Lot Size ( PM I <br /> Owner's Name µ L tit <br /> ell Address �41&1414' Phone <br /> a : <br /> Contractor's Name <br /> u License No. g3p 7'z _ Phone � ✓ <br /> TYPE OF WELL/PUMP: NEW WELL LI WELL REPLACEMENT ElDESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ElOTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> 4., <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> O Industria! E) Open:bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing • <br /> 1-1 Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications <br /> k: Type of Grout <br /> D Public ❑"Other ❑"Delta Depth of Grout Seal YP <br /> Irrigation ---Approx. Depth LJEastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P.'• - State Work Done , <br /> Well Destruction ❑ Well Diameter Sealing Material atop 50') <br /> Depth Filler Material IBelow 50'1 I <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION 11REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) ?' <br /> Installation will serve: Residence— Commercial_ OtFSer <br /> Number of living units: -X Number o bedr ams <br /> Character of soil to a depth of 3 feet: eint Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity12�ft No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT.PLT. ❑ <br /> ' <br /> Distance to nearest: Well .- Foundation Property Line d <br /> i LEACHING LINE �No. & Length of lines •Total length/size a <br /> v'::, <br /> I FILTER BED ' `❑ Distance to nearest: Well Foundation �` Property Line ` <br /> t!. i <br /> Size-- : •�-- --'Numbe7^I. <br /> SEEPAGE PITS �3!Depth �� <br /> "SUMPS "' . ❑' 'Distance to nearest: Well yd Foundation Property Line <br /> DISPOSAL PONDS .. 13 r <br /> I I hereby certify that 1 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. s <br /> Home owner or licensed agent's signature certifies the following: "I certify thatjn the performance of the work-for whlch this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's oompensation 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 employ persons subject to workman's compensa- <br /> 1 tion laws of California." <br /> TheaTitle: <br /> d pplicant r II required inspections. Complete drawing on reverse side <br /> Signe <br /> �•" � _ [)ate:. <br /> ,- <br /> } arm x,lOF <br /> f ` FORD RTMENT USE ONLY <br /> Area <br /> . <br /> Application Accepted by Date <br /> Pit or Grout Inspection by Date `Final Inspection by Date <br /> r <br /> �{ _ <br /> 'Additional Comments: <br /> ❑ Stk 466-6781 ElLodi 369-3621 ❑ Manteca 823-7104 t] Tracy'" 635-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/.Services 1601'E. Hazelton Av`e:,P.a."Bo?c'2009. Stk., CA 9.5201 <br /> FEE AMOUNT DUE AMOUNT REMITTED L�CASH w v RECEIVED BY DATE PERMIT"NO. <br /> {. INFO <br /> H.13-24(REV.10/83) 45 1 <br /> 14-28 <br />