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s � <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ` # <br /> w ,Ll] <br /> 1601 E. HAZELTON AVE., STOCKTOIV, CA 3 <br /> Telephone (209) 466-6781 �} <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) .This application is <br /> t and/or install the work herein descr <br /> Application is hereby made to the 5anJoaquin Ordinance lNo.Health D549 for sewage or permit <br /> No. 1862 for cwell/pump and the R4i s and Regulations of he San Joaquin <br /> made in compliance with San Joaquin County <br /> Local Health District. e <br /> 11 O �'• City CA?"10 Lot Size 1 r7 PM j <br /> Job Address <br /> 4, / Phone 1 <br /> rn k/ Address lv I <br /> Owners Name x-773l-q'3'ZS� j <br /> t,t � SS Address <br /> r�a 6� <br /> ContractorLicense Nom-.' �s_ Phone � <br /> CD WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WIO -/ OTHER ❑ <br /> PUMP INSTALLATION 70' SYSTEM REPAIR ❑ S <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br />` DISTANCE TO NEAREST: SEPTIC TANK �— PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL I <br /> j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> I ❑ Open Bottom C Manteca Dia. of Well Excavation <br /> +Industrial Type of Casing sT -�-� Specifications <br /> 1.Domestic/Private Gravel Pack Ll Tracy I r7� Type of Grout G�d�ee''' <br /> ❑ Public <br /> ❑ Other El Delta Depth of Grout Seal <br /> Depth Ll 0.pprox. Surfa��Seal Installed by <br /> � �\ <br /> ❑ Irrigation ,-. ' State Work Done <br /> Repair Work Dane ❑ Type of Pump — H.P. <br /> Sealing Material (top 50') <br /> Well Destruction ❑ Well Diameter Filler Material 1Below 501 <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION Llavailableiw thine200 feettted if public sewer is <br /> installation will serve: Residence Commercial, Other ` <br /> Number of living units: Number of bedrooms N Water table depth <br /> Character of soil to a depth of 3 feet: Capacity— Method <br /> Compartments <br /> I SEPTIC TANK ElType/Mfg Method of Disposal <br /> PKG. TREATMENT PLT.❑ Foundation-� Property Line ` <br /> I Distance to nearest: Well '• <br /> I Total length/size l <br /> I LEACHING LINE ❑ No. & Length of lines <br /> Foundation <br /> FILTER <br /> Property Line <br /> Well <br /> FILTER BED ❑ Distance to nearest: <br /> Size " Number <br /> SEEPAGE PITS ❑ Depth Foundation Property Line <br /> SUMPS ❑ Distance to nearest: Well <br /> DISPOSAL PONDS ❑ <br /> I 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.g *4 work for <br /> Home owner or licensed agent's as shall not <br /> torbecome subject Ito workman's <br /> rtcompensation laws of Califoify that in the performance orn ahe Contractor's which <br /> ng or sub-contracting l signature <br /> employ any person <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 California." <br /> The applicant mus call for all required inspections. Complete drawing on reverse side. <br /> 001. Date: — <br /> Title: <br /> Signed)C <br /> FOR DEPARTMENT USE ONLY <br /> Date J Z3 —d{} <br /> Area D e <br /> Application Accepted by v�� <br /> Date <br /> Da a Final Inspection by <br /> Pit or Grout Inspection by J)RO7��S <br /> �°� <br /> Additional Comments: ❑ Tracy,` 835 6385 <br /> ❑ Stk 466 6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 k., CA 95201 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, <br /> RECEIVED BY PATE PERMIT NO. <br /> ( <br /> FEE <br /> INFO <br /> AMOUNT DUE AMOUNT REMITTED �3f <br /> + EH 13-24(REV.I/s S) 't <br /> EH 1426 <br />