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r. APPLICATION FOR PERMIT, - " <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone {209} 466-6781 <br /> {. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MAR 1987 <br /> i <br /> (Complete in Triplicate) <br /> {: oyion is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wo Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wait/pump and the Rules <br /> Local Health District. <br /> Job Address <br /> /T �.��.!�. i,we City Lot Size PM-77 2roff-,?172 <br /> F <br /> 1 1Ave <br /> Owner's Name <br /> yl � G Address `a'rL Phone <br /> #t <br /> Contractor <br /> Address �� �� � License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL -WELL REPLA EMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION EJ REPAIR C OTHER ❑ 1, <br /> DISTANCE TO NEAREST: SEPTIC TANK ��! SEWER LINESDISPOSALFLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS :.- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ia. of Well Casing A <br /> T of Casing specifications <br /> Domestic/Private 1�Gravel Pack Tracy Type . c <br /> ❑ Public <br /> ❑ Other ❑ Delta Depth of Grout Seal Type of Gr t <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installe by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diamet r Sealing Material (top 501 <br /> Depth Filler Material (Below 501 ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (Noseptic system <br /> tem permitted if public sewer isaval <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 Water table depth <br /> SEPTIC TANK El Type/Mfg - CapacityNo. Compartments <br /> Method of Disposal <br /> PKG, TREATMENT PLT. ❑ <br /> e <br /> Distanc .to nearest: Well Foundation Property Line <br /> e <br /> LEACHING LINE L1No. & Length of lines Total length/size <br /> FILTER BEDCa Distance to nearest: Well Foundation Property Line „ <br /> SEEPAGE PITS ❑ Depth Size Number <br /> o <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> � <br /> DISPOSAL-PONDS L1 _. <br /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with Sari 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,1 shall employ persons subject to workman's compensa- <br /> tion laws of Cali ornia." F <br /> The applican ust call fob all i inspect( s. Complete drawing on rs side. <br /> Signed Title: pate: + <br /> 9 <br /> R DEPARTMENT SE ONLY �J <br /> Date 7 Area <br /> Application Accepted by ) <br /> / <br /> Pit or Grout Inspection by <br /> ate a6` Final Inspection by Data <br /> Additional Comments: <br /> ❑ Stk 466-6781 L1 Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy 835 6385 <br /> Applicant - Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> tt E' <br /> f FEE AMOUNT DUE AMOUNT REMITTED. RECEIVED BYEDDATE PERMIT NO. <br /> INFO <br /> +EH}3-24(REV.1/a 5) 1 ! V • ao 4�a3 - g7 • �S7-S9 <br /> EH 14-26 <br />