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f <br /> a, APPLICATION FOR PERMIT i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 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 Addressa •�4� 15., slity Lot Size 1� ,� PM <br /> Owner's Name Phone <br /> ddress s I_icenso.JABS!/ Phan ; <br /> YPE OF WEL PUMP: NEW WELL ❑ WELL REPLACEMENT TRUCTI N ❑ <br /> PU INSTALLATION ❑ SYSTEM RE L] <br /> ❑ OT R ❑ <br /> DISTANCE TO N REST: SEP TANK SEWER LINES DISPOS FLD. PROP. LINE <br /> FOUND[ ON AGRICULTURE WELL OTHE ELL PITS/Is-le S <br /> INTENDED USE ,y TYPE OF PROBLEM AREA CON CTION SPEC, ATIONS <br /> ❑ Industrial Open Bottom "''� nteca�a. of Well Excavat' Dia. of Wel] Casingr <br /> ❑ Domestic/Private ravel Pack ❑ Tracy Type of Casing Specifica26.1, <br /> { <br /> FI Public f-! 0 �� f-1 Delta Depth of G Seal Type of 1i Irrigation —App epth I 1 Eastern Surfa eal Installed by kk �a - <br /> f.Repair Work Done ❑ Type of Pump ' P s[ State Work Done J <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> fi p tl3r. �Ier:Material:.(.Belowm50_ : - <br /> TYPE OF SEPTIC WORK: W lNSTAL'LATIO RE IR/ADDITION DESTRUCTION l I�[No septic system permitted if public sewer is <br /> ;available within 200 feet.) 1 <br /> Installation will serve: Resikience Commercial Other <br /> a,,ca-yrs- I <br /> Number of living units: _J.� r ofberoom <br /> !, <br /> Character of soil to a depth.of f t: } Water table depth <br /> (SEPTIC TANK ❑ ,I.Typ,/Mfg I Capacty No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal.010 <br /> JDistance to nearest: W6 Foundation roperty Line <br /> ae <br /> y <br /> LEACHING LINE No. & Length of lines Total le,gth/size t'b <br /> ,FILTER BED ❑ Distance to nearest: Well RS-i Foundation roperty Line F, -5 <br /> I _ ¢ <br /> SEEPAGE PITS Depth 152Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation; 7— Property Line <br /> DISPOSAL PONDS ❑ f <br /> I hereby certify that I have s lic�tion and that the work will be done in accordance with San Joaqui county oS ances?state laws, and <br /> rules and regulations of the Iir> ealth Di§trict. w� <br /> Home owner or licensed agent's signature 'ties the following: "I certify that in the pe r ^�+ f wcft for�irhich this permit is ihied, I shall not <br /> i employ any person in such manner as o ubiect to workman's compensation IawsUNNACo racto s hiring or sub-contracting signature <br /> certifies the following: "I certify that inVnce of the work for which this permit is issued, I shall employ persons subject to workman's compensa i <br /> tion laws of California." <br /> IThe applicant must call for all re 7e Ins ctions. Com ilete drawing arse side. <br /> Signed Title:' _ ' Date: '--' - <br /> x <br /> DEPARTMENT USE ONLY "�- <br /> f a r . <br /> t D <br /> &it,.n <br /> ian Accepted by7Date Area• Cllow <br /> routInspection byn Date "� Final Inspection by Dateal Comments: i I 1 <br /> ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ° <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 <br /> � n <br /> CK4r <br /> FEE AMOUNT DUE >.ii AMOUNT REMITTED CASH RECEIVED BY PATE PERMIT NO. <br /> INFO <br /> 1 <br /> � J� ry �-^ g jf�( <br /> +.EH EH1/-291REV.1in51 J ' {V� l l rL7-� �Id7/�. a i- d Ir, <br />'I - <br />