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APPLICATION FOR•PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 3 <br /> 1601 E. HAZEILTON 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 J aquin 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 R41es and Regulations of the San Joaquin <br /> Local Health District. : <br /> Job Address J S-7 City [ ",,Lot Size " i k PM <br /> s /SOwner's Name Address Phone <br /> Contract § ` Address I 7_ o �'u' License�,No. .? a� Phone wl� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL.REPLACEMENT ❑' �, DESTRUCTION ❑ <br /> PUMP INSTALLATION L3SYSTEM RE AIR ❑ 1 y L OTHER 13 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWEWLINES `DISPOSAL FLD. PROP. LINE , <br /> FOUNDATION i AGRICULTURE WELL OTHER Mt_b' PITS/SUMPS <br /> INTENDED USE , TYPE OF WELL { PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial E.Open Bottom ❑ Manteca Dia. of Well'Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ..9 <br /> ❑ Public ❑ Other'*` <br /> 11 Delta t Depth of Group;Seal Type of Grout— <br /> EJ <br /> ❑ Irrigation ---Approx. Depth-�❑ Eastern Surface Seal Installed by <br /> f cs <br /> Repair Work Done ❑ Type of Pump H.P. i / ate Work Done <br /> Well Destruction ❑ Well Diameter �ealirig Mate��,(t p.501) <br /> Depth i Filler Material,(-Below 50'1_ — --- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADS ION 0 DESTRUCTIONnD❑ (No septic system permitted if public sewer is <br /> r j -available within 200 feet.) <br /> Installation will serve: . Residence Commercial— Other T- <br /> Number of living units: Numbaoedrooms,,14 �, <br /> Character of soil to a depth of 3 feet. k ^s,;�+ • ?Water table depth O <br /> SEPTIC TANK Type/Mf Capacity, No. Compartments <br /> PKG: TREATMENT PLT. ❑ <br /> t C Method of Disposal <br /> Distance to nearest: I W84A o Foundation f49 Property Line 45-- 4 <br /> a <br /> T X <br /> LEACHING LINE- lr,-No. & Length of linesU Total length/size <br /> 14 <br /> FILTER BED ❑ Distance to nearest: i weI1-.S 0 Foundation 14 Property Line 45_ <br /> i. <br /> SEEPAGE PITSDeptht Size— 1 Dumber <br /> SUMPS ❑ Distance t0 nearest: f We Foundation /10 Property Line�s <br /> j 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. <br /> Horne 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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." l <br /> The applica ust call for requ'ed girsspections._Complete drawing on reverse side. <br /> Signed XTitle: Y F Date: <br /> FOR7-4­ <br /> TMENT USE ONLY p' _ <br /> Ap lication-'it! <br /> - _ .,..�.' Date_ <br /> � <br /> it r Grout Inspection by Date f=inal Inspection by . <br /> ate <br /> 1 <br /> Additional Comments: <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.O. Box 2009, Stk., CA 95201 <br /> t .1.. <br /> i FEE <br /> INFO MOUNT DUE,' AMOUNT,REMITTED CASH RECEIVED BY DATE PERMIT"N0. <br /> ry + <br /> + EH 13-24(REV.S/65) LA <br /> � ` � "%• "' � �� `"� �/17 <br /> EH 14-26 —il. . <br />