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APPLICATION FOR PERMIT <br /> SAN JOAQUI N, -,LOCAL-HEALTH DISTRICT NDS f <br /> 1601 E. HAZEL TON AVE,, STOCKTON, CA <br /> Telephone (209) 466-6781" <br /> PERMIT EXPIRES 1"YEAR FROM DATE ISSUED, N <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 dosc rib(id.This application is <br /> made in compliance with San Joaquin Cod,rity 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 /> _c , . , - <br /> k1 LAI V_�_ , F(!!f! <br /> City Lot Size PM <br /> Job Address <br /> Phone <br /> Name A <br /> Owner's N Address <br /> Vlen 7- <br /> Contractor's Name '&49 kle Aos �wv_bcense No. Phone <br /> TYPEOFWELL/PUMP: NEW WELL I--] WELL REPLACEMENT 0 DESTRUCTION Ll <br /> REPLACEMENT <br /> 0 DESTRUCTION <br /> ''UN LJ <br /> 0 <br /> PUMP INSTALLATION F] SYSTEM REPAIR El OTHER D <br /> LINE <br /> DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES __ DISPOSAL FLD.� LINE <br /> PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL..-_ OTHER PITS/SUMPS <br /> STSP CIF C TIO S <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR SPECIFICATIONS <br /> Bottom 0 Manteca a. <br /> �o f W611 Excavation Dia. of Well Casing <br /> LI industrial 11 Open . El T of Casing— Specifications <br /> D Domestic/Private C1 Gravel Packyo� Type <br /> Ll Public 0 Other L1 Delta Depth of Grout Seat Type of Grout <br /> D Irrigation - ox. Depth L03 Eastern Surface Seal Installed by <br /> Repair Work Done ype of Pump H.P. State Work Done <br /> Well D ion 5 Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 601 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 171 REPAIR/ADDITION El DESTRUCTION]A (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> installation will serve: Residence— Commercial Other <br /> Number of living units: — Number of bedrooms <br /> ti <br /> Character of soil to a depth of 3 feet: —Water table depth <br /> SEPTIC TANK EJ Type'/Mfg Capacity_ No. Compartments <br /> Method of'DispoW <br /> PKG. TREATMENT PLT. El Property Line <br /> Distance t; nearest: Well Foundation <br /> LEACHING LINE El No. & Ler�thof iine s Total length/size <br /> FILTER BED 0 Distance to'nearest: Well Foundation Property Line <br /> SEEPAGE PITS 0 Depth -Size Number <br /> 40 Property Line <br /> SUMPS El Distance nearest: well Foundation <br /> DISPOSAL PONDS. EI <br /> I hereby certify that I have prepared thid 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 shalt not <br /> become subject to workman's-r-ompensiitio6-laws.of..California.-.Contractoes hiring or sub-contracting signature. <br /> certifies the following:" <br /> employ any person-in such manner as to 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 /> T applicant mus II for all required inspections. CoM@1a <br /> The te drawing on reverse side. <br /> Date: <br /> fined <br /> FO DEPARTMENT�USIE ONLY <br /> LY <br /> Area <br /> Application Accepted by OQL <br /> Pit o.r Grout Inspection by Date Final ripection by Date <br /> —U(AZ <br /> Additional Comments _7V, <br /> 0 Stk 466-6781 '- 0 Lodi 369-3621 El Manteca 823-7104 El Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2101, Stk.,'CA 95201 <br /> FF­EEECEIVED BY pAfE' PERMI-r'No! <br /> AMOUNT DUE. AMOUNT REMITTED ASH R <br /> X7 <br /> EH 1324[REV.10183 <br /> 1 00 <br /> 1� •i 1428EE-I <br />