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3 <br /> APPI_ICATIUN FOR PERA1IT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 463-6781 <br /> _PER_M_IT_r_XP_IRES_1 YEAR FROM DATE ISSUE_fl_ <br /> (Complete in Triplicate) <br /> Application is hereby rnaue to the San Joaquin Local Health District for a permit to construct and/or install t to work herein described. This applicati,-n is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewago or No. 1652 for well/pump and t ic Rules and Regulations of the San Joaquin <br /> Local Health Distrct. <br /> Job Address _ ,p a 1- —St�1fL l±�Q— CityL�'!'�_` \size N e PM <br /> r : <br /> ,�.cT ' SS l Lb2aL e <br /> Owner's Na s —_ � _ Address ._ Phone _ k <br /> l.onlractor TCA z _ Address!_a r License No 35 Phone �+�+" <br /> TYPE OF WELL/PUMP: NEW WELL 1.1 WELL REPLD. EMENT F_l DESTRUCTION LI <br /> PUMP INSTALLATION 1-1 SYSTEM REPAIR Ll OTHER D It <br /> DISTANCE TG NIAREST: SEPTIC TANK SEWER LINES ___ DISPOSAL FLD. _ PROP LINE <br /> cOUNDATION AGRICULTURE WELL OTHER WELLPITSrSUNIPS <br /> INTENDED USE -TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1.1 Industral O Open Bottom ❑ Manteca Dia. of Well Excavation _ D,,. of Well Casing _ <br /> I1 Domestic/Private 1_1 Gravel Pack 1-1 Tracy Type o1 Geeing.—____ Specifications <br /> I" Public r_1 Other 1-1 Delta Depth of Grout Seal _- Type of Grout__ <br /> I ' hrigation _—.Approx. Depth I I Eastern Swface Seal Installed by - <br /> Repair Work Done f] Type of Pump _ H.P. _ State Work DoneWell Destruction rl Wea Diameter Sealing Material(top 50') <br /> Depth Fiber Material(Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is �r <br /> available within 200 feet.) hf <br /> Installation will serve: Residence— Commercial <br /> Number of living units: Number of bedrooms <br /> Charaster at soil to a depth of 3 feet: d!ZAA.)P _Water-able depth <br /> SEPTIC TANK, p�­Type/MfgC.Cl^+ CapaciryfSdsl.— No Crrmp3rtments <br /> PKG. TREATMENT PLT.U Methodof Di' o$ai _ <br /> Distance to nearest: We11 ;54!, o Foundation 1v Property Line ' <br /> � .J <br /> i_F4CHiNG LINE P"No. R Length of lines C, Total length/size_ <br /> FILTER RED C_I Distance to nearest: Wetl, Foundation P Property Line—tQV I <br /> SEEPAGE PITS I I Depth —,— _Size Number <br /> SUMPS I I Distance to nearest: Well_ Foundation Property Line <br /> DISPOSAL PONDS Il <br /> I hereby certify that I have prepared this application and that thn�-.ork will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the S n Joaquin Local Health Distrir;c. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performanc9 of th, �i ork for which this permit is issued, I shall not <br /> employ any person in such nner as to become Tu ct to workman's compensation laws of California."unntractor's hiring or sub-contracting tignature <br /> certifies the following: "I r.ify that in the Per, a of the work for which this permit is issued,I shall emp'oy persons subiuct to workman's compensa- <br /> tion laws of Calif orni <br /> (lin app1, t m c r or all required i ctions. o et rawing on re' side. <br /> Signed X _ _ Title: _ �� Date: <br /> DEPARTMENT USE ONLY cr / <br /> application Accepted by -� L7 ` �? Date Area <br /> Pit or 0-out Inspection by - ._ / Date sinal I 1pection b _ Data <br /> i,ddidonal Comments: <br /> St. 466.6781 ❑ Lodi 369--362� P Mpnteca 8243-7104- 1 C1 Tracy 83 -"5 <br /> pp;icant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave, P.O. Box 21109, St',,, CA 15201 pl` <br /> FEE AMOUNT DUE .AMOUNT REMITTEU CK RECEIVED BY DATE lERMIT'NO. ' <br /> INFO J�,, CASH <br /> ;1 iNEV i-npi <br /> -70Q`- <br /> 7 `` rn <br /> f <br /> ( <br />