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""ter <br /> APPLICATION FOR PERMIT M.~ v- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA -"" <br /> Telephone (209) 466-6781 - <br /> PERMIT EXPIRES 'I 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. <br /> Job Address .�[L•lJ 0442/4 City Lot Size ` PM <br /> Owner's Name l J, /7 , y � Address <br /> Contractor '1lfddfess S � r <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEM T ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERS❑__ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F'LDPROP- LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well ExcavAjuo�n Dia. of Well Casing <br /> 'J_�omesticlPrivate )&_Gravel Pack t9,Tracy Type of Casing Specifications _ <br /> FI Public (7Other nDelta Depth of Grout Seal f� /1'­_� Type of Grou <br /> � <br /> I i irrigation 13V—,.Approx. Depth I I Eastern Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump H-P. - State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material [top 50'1 <br /> Depth Filler Material (Below 50') -- <br /> \V( TYPE OF SEPTIC WORK: NEW INSTALLATION I'l REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> t Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> �v Character of soil to a depth of 3 feet: Water table depth <br /> t!S SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal O <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> [ ti4 FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> ter` SEEPAGE PITS i I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 /> 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 C ni " <br /> The appli n al or a rtspections. Complete drawing on r se side. <br /> Signed X Title Date: <br /> r <br /> FOR R EPARTMENT USE Y <br /> Application Accepted by Data Area <br /> Pit or Grout Inspection by Date Final Inspection by ate 6 /s <br /> Additional Coma.tnts: ` <br /> ❑ Stk 466-6781 m0 Lodi 3W3621 ❑ antece 823-7104 ❑ Tracy fi385 <br /> Applin Return all copies to: Environmental Health Permit/ ervi s 1601 E./Hazelton Ave/., P.O. Box 2009, SiikC., CA 95201 <br /> 7 AI c f�6[�d . /Ju ®�ceLS f� !1�74 A5e.n r+'h r T elven ebi fi )11 ,�% � 5 <br /> FEE NT E AMPUN REMITTED CK ( RECEIVED BY DATE PERMIT'NO. <br /> INFO AMOUNT CASH <br /> -EH 13-241REV-1/A 51 Lxt <br /> ` 11r/2EH 14-2al/ __— --- - -- /! <br /> �r <br /> I 7 -�".C'! 'r .s.:, .-._�.-�-�:r � -r,,Q�s was r,�. In.a/t <br />