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a APPLICATION FOR PERMIT <br /> 610D 4o' i 64& 4 3k`- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �1,,�� <br /> 1641 E. HAZE i ON AVE., STOCKTON, CA h� G Wie~.Yi.e,6 yam. <br /> f . . <br /> Telephone (209) 468-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is heFeby 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. [ <br /> Job Address a1.�4� � ,� Z City Lot Size E /p�L eAI��S PM <br /> Owner's Name _w_ry_el rim Address ( �l__._�.-__.__ �1�1!'I�7 7�_-_. Phone <br /> Contractor Address Z11 lo License No. Phone f�{ <br /> TYPE OF WELL-/PUMP: NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION ❑ <br /> PUMP"INS�AIZL-ATiON--❑ - —SYSTEM-R-EPAfR—C1�,.-OTHER--,p-.--..— <br /> DISTANCE ST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> F AGRICULTURE WELL` OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PRO CONSTRUCTION SPECIFICATIONS <br /> e'en=lgdiiSfGFBIy .--..©-open-Bottom ❑-.Manteca.�....,_:,,. Dia-_ Excavation. Dia: of Well Casing <br />�,. v <br /> (� Domestic/Private © Gravel Pack ❑ Tracy ¢ Type of Casing Specifications — <br /> 1-1 Public ❑ Other Ll Delta,- ' Depth of Grout Seat '"'' Type of"Growl <br /> I I Irrigation �_Approx. Depth ( I Eastern Surface Seal Installed by _ <br /> Repair Work Done 11 Type of Pump H.P. State Work Done._ <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50') <br /> Depth Filler Material {Below 501 # <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION Jif DESTRUCTION I I (Nosepticsystem permitted if public sewer is <br /> available within 200 feet.) r <br /> Installation will serve: Residence 4- Commercial_ Other <br /> Number of living units: _> Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity '" 4 No. Compartments \ <br /> PKG. TREATMENT PLT. ❑ Method of Disposal (� <br /> Distance to nearest: Well-Foundation Property Line <br /> LEACHING LINE k1 No. & Length of linesotal length/size <br /> Al- AJ <br /> FILTER BED ❑ Distance to nearest: Weil 160 Foundation'— f Property Line <br /> SEEPAGE PITS ISI Depth Size E.f Number <br /> SUMPS Ll Distanceto nearest: Well 17 Property Line <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 Di$trict. <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 <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." <br /> The applicant must call for all required rction . Complete drawing on reverse side.- t <br /> Signed ills: Date: <br /> FO_ DEPARTMENT USE ONLY <br /> Application Accepted by C( s _\j Date ! o` Area <br /> F T <br /> Pit or Grout Inspection by Date F! al Inspection by Date 1 y <br /> Additional Comments: A.,wtA cc, G ► { � j <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 /> 1 <br /> FEE <br /> INFO �AMOUNT DUE A O NT REMITTED CASH RECEIVED BY DATE PERMIT'NO.Q <br /> r.EH114-2a 3-24 IRE <br /> EH V.1/H 5 O" <br /> 1 / t //�' ?/ <br /> //Q-/ <br />