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n <br /> APPLICATION FOR PERMIT <br /> f- SAN JOAQUIN LOCAL HEALTH DISTRICT J - � <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209)A46-6ipffj 4(0,S3400 1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED F'R r"�jVrQ <br /> (Complete in Triplicate) � � Th <br /> F Application is hereby made to the San Joaquin Local Health District fora permitp s <br /> � rh . / <br /> made H compliance with San Joaquin County Ordinance No. 549 for sewage or No, 1B&2 forcwell plumor p and he Ruthe les and in desa described. <br /> This the San anon is <br /> Local Health District. <br /> Job AddressL /J <br /> City. v Lot Size � G-_ <br /> x r �} M <br /> Owner's Name <br /> 'Address <br /> Contractor Phone �� �o <br /> Address <br /> TYPE OF WELL/ UMP: NEW WELL ❑ License No.�___�L Phone_ <br /> PUMP INSTALLATION ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 <br /> DISTANCF'TO NEAREST:s SEPTIC TANK SYSTEM REPAIR ❑ --� OTHER aw-� 2�.,��AeZ, <br /> I <br /> SEWER,LINES"" `�* <br /> DISPOSAL FLD;OUNDATION- - r. PROP. LINE <br /> w �= AGRICULTURts.WELL r- OTHj R.WELL PITS/SUMP <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION'S PECIFICATIONS z r <br /> ❑ Industrial ----- ,_. ; <br /> ❑.Open Bottom -� <br /> ❑ Manteca Dia. of Well Excavation <br /> Q Domestic/Private EI Gravel Pack ❑ Tracy Dia. of Well Casing <br /> M —'/4 H <br /> Public Type of Casing <br /> F1] Other 171 Delta T Specifications <br /> Irrigation 4 Depth of Grout Sea! Type of Grout <br /> 1 1 Eastern <br /> —_Apprax. Depth Su Seal Installed by <br /> Repair Work Done F1 Type of Pump r✓o 41 A. <br /> Wel! Destruction Q Well Diameter�.�—fo "" <br /> H.P' Lteriaf <br /> StateWork Done <br /> Sealing ltap 50') ! <br /> Depth +� Filler Materia! (Below 50') <br /> TYPE QF SEPTIC WORK: NEW INSTALLATION I.1 REPAIRfADDITION—IF.I DESTRUCTION ! I %1 o septic system permitted if public sewer is <br /> Commercial Other ` <br /> Installation will serve: Residence available within 200 feet.) <br /> � � <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK <br /> ❑ Type/Mfg 'I Water table depth y PKG. TREATMENT PLT. ❑ Capacity No. Compartments <br /> Method of Disposal <br /> Distance to nearest: e I Foundation <br /> � Property Line � <br /> LEACHING LINE ❑ No. & Len f lines <br /> FILTER BEDTotal length/size I <br /> ❑ Dista to nearest: Well Foundation <br /> I _ Property Line <br /> SEEPAGE PITS Depth Size <br /> Number <br /> SUMPS <br /> t7 Distance to nearest: Well Foundation <br /> DISPOSAL P DS ❑ Property Line <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 /> _ <br /> Home 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 j <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." I j <br /> The.appiicant a al erred i etions. Complete drawing on reverse sid <br /> I <br /> Signed X T <br /> Title: <br /> Date: <br /> FORcDEPARTMENT USE ONLY <br /> Application Accepted by f� ��, ! <br /> Date ! Area <br /> Pit or Grout Inspection by Date <br /> Q Final Inspection by Date <br /> Additional Comments: / !f` r . <br /> ❑ Stk 466-6781 ❑ Lodi 359 <br /> ❑ Ma rata 823 7 ❑ Tracy 635-6385 ` pr-��o str <br /> Applicant- Return all copies to: Enviro mental Hea)th Permit/Services 1601 E. Hazelton Ave., P.O ox 009, Stk., CA 95201 <br /> � r � Q five be As <br /> FEE _. y _ <br /> INFO AMOUNT DUE I AMOUNT REMITTED <br /> CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 1 i <br /> 3-24lREV:� xsl �� <br /> EH 14-28 .�� U v (f <br />