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1. APPLICATION FOR PERMIT � "'�4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT f.-..4 <br /> 1601 E. HAZEL—1 ON AVE., STOCKTON, CA A JV <br /> Telephone (2091466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C1f 1✓��� <br /> 1989 <br /> (Complete in Triplicate) 290SW ication is <br /> ermit to construct andlor install.the work her iagain <br /> Application is he+eby made to the San Joaquin Local Health 649for far a p <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regu <br /> Local Health District. <br /> / City Lot Size PM <br /> Job Address <br /> Phone <br /> Address s <br /> Owner's Name n ."3 Mc ��. <br /> Address t-it nse No <br /> � � Phone <br /> ContractorWELL REPLACEMENT ❑ DESTRUCTION El <br /> OF WELL/PUMP: NEW WELL DESTRUCTION <br /> SYSTEM REPAIR <br /> PUMP INSTALLATION C1 -DISPOSAL FLD. Z PROP. LINE <br /> f'�SEWER-LINES —� <br /> ,.DISTANCE TO IVEAREST.:,SEPTIGTANYC AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> FOUNDATION <br /> i_ WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WE ❑ Mane teca pia. of Well Excavation f Dia. of Well Casing <br /> ❑ Industrial EJOpen Bottom Specifications <br /> ❑ Trac Type of Casing _ <br /> C omestic/Private ❑ Gravel Pack y Depth of Grout Seal Type of Grout <br /> l-1 Other f-1 Delta _ <br /> r i'1 Public ApproxI I Eastern j Surface Seal Installed by <br /> I I Irrigation �.- . Depth,. <br /> _�. 1� State Work Done <br /> Type of Pump 4Q�� H.P. a <br /> Repair Work Done y \ <br /> Well Di '• Sealing Material (top 50'1 <br /> Diameter . <br /> r Well Destruction ❑ Filler Material (Below 501 <br /> I Depth <br /> F available within 200 feet.) <br /> TYPE OF SEP71C WOflK: NEW INSTALLATION I l REPAIRlADDITION Ail OESTRUGTION I I (No septic system permitted if public sewer is <br /> F Installation will serve: Residence, Commercial'�Other_. <br /> Number of bedrooms 5 ' <br /> �Number of tieing units: .. Water table depth <br /> Character of soil to a depth of 3 feet: Capacity- No, Compartments <br /> r SEPTIC TANK 0 Type/Mfg <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest:`-6 Well t Foundation Property Line V� <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Foundation Property Line <br /> FILTER BED ❑ Distance to nearest: Well <br /> i Number <br /> SEEPAGE PITS l 1 Depth Size — = <br /> SUMPS L-; Distance to nearest: Well <br /> Foundation Property line. <br /> ' <br /> —DISPOSAL PONDS ❑ <br /> i I hereby certify that 1 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. i _ <br /> I Home owner or licensed agent's signature certifies the following: "l certify that in the performance of the'work for which this permit is issued, I sign not <br /> s of California." Con <br /> employ any ersonin such certify that n to become the performancesub <br /> cof�he work for which thss permit <br /> ation is issued, I shall.amploy personssubjectring to work <br /> man1s-contracting <br /> cert) following: <br /> r tion laws of California." <br /> The applica 1 or all r e inspections. Complete drawing on r erse side. <br /> eJ Date: <br /> .� <br /> Signed X Title: � <br /> FQR DEPARTMENT USE ONLY, l ^, <br /> Date `7 Area <br /> Application Accepted by vv�S" <br /> Final inspection by to <br /> t Pit or Grout Inspection by Date q f <br /> I Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ElManteca-823-7164 . ❑ Tracy 835 6385 Stk., CA 95201 <br /> Applicant- Return all copies to: Environmental Health Permiit/Services 1661 E. Hazelton Ave., P.O. Box 2009, <br /> L <br /> CK RECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO C-1 ?-2441 <br /> + EH 13-24(REV.1/n 51 `-' C <br /> EH 14.26 <br />