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APPLICATION FOR PERMIT <br /> 4 SAN JOA®U11V9LOCAL,hIEALTI-I DISTRICT <br /> 1601 E. HAZELTON AVS,, STOCKTON, CA <br /> ;= Telephone {209} 466-6781 <br /> I. _PERMIT EXPIRESTYEAR 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 her in <br /> This application is <br /> made in compliance with San Joaquin County Ordinance No.-549 for sewage or.No..1862for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. t s� vilA <br /> 1�:` ic�Z 1 � '� '.R — City�l K.T O N Lot Size PM <br /> Job Address _ R : <br /> Address -� Phone <br /> Owner's Na h <br /> 0 0 4 �" ��TC r License No. 14 X I/ Phone <br /> C tractor s me . <br /> TYPE OF WELL/PUMP: 1! NEW WELL WELL REPLACEMENT ❑ DESTRUCTION LlPUMP INSTALLATION SYSTEM REPAIR ❑ OTHER El tit <br /> DISTANCE TO NEAREST: SEPTIC_TANK _.SEWER LINES _ DISPOSAL FLD. PROP. LINE _ r <br /> ' � WELL PITS/SUMPS <br /> FOUlVDAZION� _ AGRICULTURE WELD = _ _ _ i <br /> INTENDED USE. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n <br /> -❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excava`t, n Dia. of Well Casing <br /> L7 Domestic <br /> Gravel Pack El Type of Casing V TSF.4 SP ecifications <br /> lPrivate <br /> ❑ Public ❑ Other, ❑ Delta Depth of Grout Seal Type of Grout <br /> A16 Al 9� <br /> )(Irrigation �Approx, Dept ❑ Eastern -Surface Seal Installed by <br /> i Repair Work Dona ❑ ,Typa:Of;Pum p H. State Work Done- y <br /> Well Destruction ❑ Well D metier it - Sealing Material (to501 <br /> c Depth �., 'f�' Filler Material (Below 501 <br /> r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Q DESTRUCTION ❑ INo septic system permitted if public sewer.is v1 <br /> ir�Q,T ,.,..r, vv I .�.R :�,�.�1 h i available,wittiin 200 feet.) <br /> Installation,wmll`se.Ne N F,esidence Commercial_ Other s <br /> Number of living units: <br /> Number of bedrooms _ depth <br /> -Character of <br /> 3 feet: <br /> SEPTIC TANK'soil to depth Ty'a/Mfg Capacity .o.t CrompaJ rt�menti T <br /> p % <br /> 11 11 <br /> PKG. TREATMENT PIT ❑ e s Method of Disposal <br /> Distance to Barest:-4 Welk Foundation t Proper�ty�L:in� <br /> LEACHING LINE ❑ No. & Length of lines Total length/size- <br /> -F <br /> ength/size <br /> FILTER BED ❑ Distance to nearest: Well '""'"Four dation '� ---Property-Line ' <br /> SEEPAGE PITS Ic Depth Size Number 1 <br /> SUMPS ,v. f #` El Distance to nearew:��- z Well — -Foundation- —Property Line - i <br /> DISPOSAL PONDS 4 ❑ <br /> ' �work will be done in accordance with San Jogquin county ordinances, state laws, and <br /> I hereby certify that.l have prepared this application anti thet`tfie <br /> rules and regulations df the San Joaquin Local Health District. ""` <br /> Home owner or licensWagent'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 hiringo6t sub-contracting signature <br /> certifies the following:"I certify';that in the performance of the work for which this permit is issued?Is4hall employlpersons supject <br /> tion laws of-Cal' ia -to workman's compensa- <br /> " - = <br /> The applicant st '1(!f or required inspects ns. Complete draEATMENT <br /> lde. <br /> t T <br /> Signe <br /> f5 NI r OR DUSE ONLY <br /> f Date ,f7s 'Area <br /> Application Accepted by: <br /> - -, "i •� Date <br /> o Y <br /> ' Pit or Grout Inspection by Date Final inspection by <br /> Additional Comments:'�f—', <br /> ❑ Stk 46fr6781 L1lodl 369i3Ef �O Mantes a 1823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to'.Environmental 14ealth-�Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201"`- <br /> FEE 'AMOUNT DUE AMOUNT,REMITTEp CASH RECEIVEIS BY ' a DATE PERMIT;NO. <br /> ;�.. INFO _ a <br /> o <br /> + EH 13.24 IREV.10/83) f <br /> ' EH 14-28 <br />