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APPLICATION FOR PERMIT <br /> SAN .JOAnUIN LOCAL HEALTH DISTRICT <br /> o� l <br /> `k r 1601 E. HAZELTON AVE., STOCKTON, CA <br /> ! Telephone (209) 466-6781 <br /> r PERMIT EXPIRES tYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> { <br /> Application is hareby 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 - E• r City Lot SizePM <br /> I ` - — <br /> Owner's Name Address �, Phone, <br /> hon ��r. `6-7, <br /> Con In, <br /> Address Q C1 ,L icens-6 No, S �!Phon jQ <br /> d_ TYPE <br /> OF WELLIPUMP: ,NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ -. <br /> PUMP INSTALLATION ❑ . SYSTEM REPAIR El "ITT-WE O O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER ONES-- --T "—rOISPOSAL FLD. PROP. LINE <br /> FOUNDATION 'AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i INTENDED USE TYPE OF WELL P60BLEM,AREA.�CONSTRUg1ON SPECIFICATIONS <br /> ❑Industrial ❑ Open Bottom - ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> f ❑ Domestic/Private ❑ Gravel Pack El/Tracy Type of Casing Specifications <br /> ['t Public F-1Other <br /> 41 ll Delta Depth of Grout Seat Type of Grout <br /> S3 t l Irrigation —Approx. Depth 11 Eastern `t �SurfaceSeai Installed by, <br /> r -- <br /> L Repair Work Done ❑ Type of Pump ..H.P. State Work Done <br /> Well Destruction ❑ Well Diameter ! Sealing Material(top 501 <br /> DepthFillerWaterial(Below SO-) P <br /> 4 <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION R PXIRlADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 1 <br /> 4 1L ' },a' avail to within 200 feet.) <br /> j) Installation will serve_' Residence? Commercial,� Other <br /> Number of living units: Number f ed' ms <br /> Character at soil to a depth of 3,180 t: (' Water table depth t�Q <br /> ' SEPTIC TANK Type/Mfg f` Capacity -e No. Compartments <br /> PKG.TREATMENT PLT.❑ Method of Dilsposa( <br /> Distance to nearest: Well Foundation 16 - Property Line . S <br /> \ . r <br /> LEACHING LINE LN4 No. &Length of fines © Total length/size <br /> FILTER BED ❑ Distance to nearest: We � Foundation)f/ Property Litre -� f <br /> SEEPAGE PITS I', Depth IS7f& Size Number <br /> SUMPS (1 Distance to ne rest: Well Foundation _ 112 _ Property Line <br /> DISPOSAL PONDS 0 f <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 la_wa, and <br /> rules and fegufations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I cer0y that in the performance of the work for which this permit is issued, f shall not <br /> ' employ any person in such rnanner as to become subject 6workmans�mpensation taws of California."Contractor's hiring or subcontracting Vgnawffl <br /> certifies the following: "I certify that in the perfWrnance-of the work for which this permit is issued,I shall employ persons subject to workman's combensa- <br /> tion laws of California." <br /> The applicant m cats for all uir inspections. Complete drawing on reverse <br /> Signed X Title: - ' Date:/ <br /> QRPARTfMENT USE ONLY <br /> F. App ication Accepted by r Date v � Area <br /> Pi o : <br /> r Grout inspection by Date Final inspection by Data <br /> 110i Additional Commentsd <br /> ('< ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manletai 823-7104 ❑ Tracy 835-6386 <br /> jApplicant- Return all copies to: Environmental Health Pe4nit/Services 1601 E. Hazatton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> i <br /> F O AMOUNT DUE AMOUNT REMITTED CASH it RECEIVED BY DATE PERMIT'NO. <br /> `y. ♦ 1241REV.i/n57 <br /> E,H �QrUb U.. <br /> (� EH 14-4-2s 4 <br />