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1 xp APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> " 1601 E. HAZELTON AVE-, STOCKTON, CA <br /> Telephone (2091 466-6781 <br /> PERMIT EXPIRES 1"YEAR FROM DATE ISSUED <br /> 1 (Complete in Triplicate) <br /> f Apolication is hereby made ro the San Joaquin i Deal Health Oistrict for a permit to construct and/of install the work herein described. This application is <br /> II{ made in compliance with San Joaquin County ordinance No.$49 for sewage or No. 1862 for we41/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /># �/� /� <br /> Job Address 3/ S �//aGc-/ s��(lc� " City Lot Size <br /> L, PM <br /> Owners Name -S�+G/ (�i II O Address -3 9 d J O i4ls c( Phone 5 -)4/),/ <br /> 7 <br /> t I l�FJ1VG�7t7 CprGL.o v.RJ. 9 <br /> Contractor I a P.11 9.M,44 Address Z r License No. GS7•S3r4-`�71oee " <br /> TYPE OF WELL/PUMP: NEW WELL n1 .3 WELL REPLACEMENT Q DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> ii DISTANCE TO NEAREST: SEPTIC"TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS -- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom p Manteca Dia. of Well Excavation_._(U Dia. of Well Casing <br /> ❑ Domestic/Private ❑ GravelltPack Tracy Type of Casing Py,(' Specifications <br /> 171 Public Ci Other L1 Delta Depth of Grout Seal Type of Grout Cpzmj, qL <br /> 1 I Irrigation 4 Approx. Depth I I Eastern Surface Seal Installed byaly 1 F..�cj�/en7rYC0.�1f�}� _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done �~ <br /> Well Destruction C3 Well Diameter Sealing Material (top 5(y) <br /> " Depth Filler Material (Below 517) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/AOOETIQN I I OESTRUCTION l I IND Septic system permitted if public sewer is <br /> available within 200 feet_} <br /> Installation will serve: Residence L Commercial_ Other <br /> Number of living units: - Number of bedrooms l <br /> t Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ ([ Method of Disposal <br /> Distance to nearest: Well Foundation_ Property Line <br />,IE 1 <br /> K LEACHING UNE. ❑ No. & Length of lines Total length/size <br /> i, FILTER BED ` <br /> ❑ Distance to nearest: Wn11 Foundation Property Line <br /> SEEPAGE PITS I I Depth _Size Number <br /> t 1 SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> N DISPOSAL PONOS ❑ <br /> 1 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 pistrict. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the wont for which this permit is iswed,d shall not <br /> ra ti <br /> employ any person in such manner as to become subject to workman's compensation laws of California.',Contractors hiring or sub-coni-sued. signature <br /> t <br /> certifies the fallowing: "1 certify that in the performance of the work for which this permit;s issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California.,, t <br /> The appiicant st call for all requited insyec oris- Complete drawing on.reverse side. <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Q p flats ! Arm y • �1 ;." . <br /> Pit or Grout Inspection by , Date fJ Final Inspection by !tel Date ?o <br /> Additional Comnwnts: r <br /> ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ Manteca7 04 p Tracy 835.6385 <br /> Applicant- Retum all copies to: Environmental Health Perm /Services 16011 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE MOUNT REtMITTEO CK a Rr:cOveo BY OATS PERMIT'NO. <br /> h�r <br /> EHt.m `_ � r �'a0- Io �1 � ©7 <br />