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APPLICATION FOR PERMIT <br /> i.+1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE.,-STOCKTON, CA <br /> 'Telephone (209) 466-6781 <br /> PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> N: (Complete in Triplicate); .:.~ al-A-64 <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. 1962 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. �!1� t' <br /> Job Address ,- City C L�i�A)Lot Size�74 <br /> v ply <br /> k Owner's Name .address <br /> � ��qq�� ��/ _ n'q y" .0 �l Phone <br /> ContractorC�-�''tiG �- Address Lien .No Phon <br /> TYPE OFWEIL/PUMP: NEW'WECC"❑" " WELL REPLACEMENT ❑� DESTRUCTION ❑ _ <br /> I PUMP INSTALLATION 173 SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. LINE <br /> INE <br /> t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PROP. LME <br /> INTENDED USE ''"TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> PS <br /> LJ Industrial ❑ Open Bottom' ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Privatec ❑ Gravel Pack LJTracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal <br /> Type of Grout i <br /> ❑ Irrigation _A,pprox Depth ❑ Eastern .S rface, eal Installed by e {S <br /> - .S r <br /> Repair Work Done Type of Pump H.P. E State Work Done_ 3; <br /> Well Destruction 13 Well Diameter Sealing Material (tap 50') } ` <br /> Depth Filler Material (Below 50') . I <br /> t TYPE OF SEPTIC WORK: NEW INSTALLATION <br /> "O REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is i <br /> available within 200 feet') 1 <br /> Installation will serve Re idence Commercial Other i �✓ <br /> Number of living units: Number of bedroom- <br /> Character <br /> I <br /> Character of soil to -depth-of-3 feet<• �- Watertab'le depth' 'T" <br /> 3 SEPTIC TANK '~� <br /> ❑ Type/Mfg Capacity No:'Compartments._ <br /> PKG: REATMENT PLT. ❑ Method of-Disposal <br /> 1. <br /> -� Distance to nearest: Wel! Foundation ;.Property Line <br /> t LEACH1R:INE Al�No. & Len th of lines <br /> «-- g .> Total length/size <br /> FILTER-BED ❑ -Distance to nearest: Well Foundation Property <br /> SEEPAGEIPITS? ; ¢1 ❑ -Depth <br /> r ' ��} a t�Y a 4 Nymber f <br /> K'-,, - ---- - Distance-to nearest: . Well <br /> a. Foundation Ole <br /> SUMPS Property Line <br /> DISPOSA.C'PONDS ❑ <br /> I hereby certify tRat,l have prepared thisapplication and that the'work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules ind.regulations'of,the San Joaquin'Local Health District. <br /> - <br /> Home owner or licensed agent's signature certifies the following:{"certify that in the performance of the work for which this permit is issued, Ishall not <br /> employ arty person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting sig'rsature <br /> "`certifies 'e following:"I certify that in the performance of the work-for which this permit is issued,I shall employ <br /> tion la s o liforni s P y persons subject to <br /> workman's compense- <br /> The a licant` st all r all requi pections. Complete drawing on reverse side. <br /> l: , [ t <br /> f Signed t� � <br /> `' Title: t ( Date: <br /> IL�l1 l FOR PARTMENT_ USE ONLY <br /> ! Application Accepted by ��. Date #77­JP6 <br /> Area <br /> 111 <br /> Pit or Grout Inspection by '� . .Date�- Final Inspection by Date <br /> Additional Commen S: � E <br /> i <br /> ❑ Stk 466-6781 \ ❑ Lodi 369-3621.. Manteca 823=7104 ElTracy 935-6385 <br /> Applicant- Return all copies to: Environmental eal Permit/Services 1601 E.:Hazelt66'Ave., P.O. Box 2009, Silk., CA 85201 <br /> t <br /> FEE <br /> -+ <br /> ; <br /> wsl °MOUNT AM•OUNT- R�h 1INFO i CASH `FiECE.V. D_ Y l A4PER—MIT'�NOf. <br /> EH 1426EHe1 -26'IgEV.ti [[ <br /> ' <br /> • <br />