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++1 <br /> 1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL.HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {Complete in Triplicate} <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. 1862 for well/pump and theRules and Regulations of the San Joaquin <br /> Local Health District. <br /> OL <br /> Joh Address L�{i <br /> r Fh City J 4 Lot Size � PM <br /> Owner's Name % ��"Ll",� Address L' u ' V s Phone <br /> n. � <br /> Contractor�-�{r kdz_�{'� Address �Z+ �� License No. S y b Phone � <br /> TYPE OF WELL/PUMP: �� NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPOR'❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ZO d. �f._ DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS/DO ff <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO ' / d,�q <br /> El Industrial L3 Open Bottom Ll Manteca Dia. of Well Excavation Dia. of Well Casing v <br /> 1 Domestic/Private ❑ (3r&vel Pack ❑ Tracy Type of Casing �MF� Specifications f <br /> ❑ Public -FOther El Delta Depth of Grout Seal 0 + Type of Grout <br /> ❑ Irrigation !' li <br /> 9 _Approx. De th LI Eastern Surto a Seal Installed by �.j. <br /> Repair Work Done ❑ Type!kof Pump �� H.P. Y —4— State Work bone 7 <br /> Well Destruction ❑ Well Diameter - - m- -- i <br /> II --_�� Sealing Material (top 50'1 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted ifVuplic sewer is 1 <br /> q­, availablo-within 200 feet.) �'{ I� <br /> Installation will serve: Resid�nce— Commercial_ Other i i , <br /> _ <br /> , — � d <br /> Number of living units: dM Number of bedrooms ? - f <br /> Character of soil to a depth of 3 feet: <br /> Water tabie depth- <br /> SEPTIC TANK ❑ Type/Mfg Capacity' ' No. Compartments <br /> PKG .TREATMENT PLT. El '11' z <br /> Method of Qisposal .* <br /> Distance to nearest: Well_ - Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line i <br /> i` t <br /> SEEPAGE PITS ❑ Depth Size Number ¢ 1 <br /> SUMPS ❑ Distance to nearest: Well FoundationProperty Line = <br /> DISPOSAL PONDS ❑ - <br /> 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 /> Home owner 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 t <br /> employ any er on in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature <br /> certifies the oil wing:" c ify that in th rformance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of ifornia. <br /> The applic ust cal for a equlr d I do . Complete drawingon averse side i <br /> Signed Title: <br /> Date: <br /> FO DEPARTMENT USYyONLY _ <br /> Application'Accepted by Date " Area <br /> Pit or rout I pection by ( Date 9 12 A(F Final Inspection by Date X , <br /> Additional Comments: � � <br /> ❑ Stk 466-6781 ❑ Lodi ;36.9-3621 ❑ Manteca 823-7104 ❑ Tracy 8354i385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT N0. <br /> y CASH j <br /> V_EH 13-241REV.1/85r y <br /> EH 1428 '�� IU Ota- q/� 1101 f <br /> l <br />