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I <br /> APPLICATION FOR PERMIT <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f <br /> 01 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (2209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ' <br /> Application.c hereby made to the San Joaquin Local H"alth District for a permit to construct and/or install the work herein described.This application is <br /> made to comp:iance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Rnqulations of the San Joaquin <br /> Local Health District. <br /> n r r <br /> ,to!)Address Address ._ 4;j '� 1- . / /,/v _ City J /i'Coi Size //`. X Y t` PM <br /> r•,tL /.—LTJ �L—_S �� <br /> Owncr's Na �s r > Address _ y� �-� .� L ��--- Phone <br /> Contracts _S� -_-Address — —License No. Phone <br /> TYPE-OF WELL/PUMP: NEW WELL -I WELL REPLACEMENT C] DESTRUCTION C] <br /> - - <br /> PUMP INSTALLATION I I SYSTEM REPAIR i, OTHER Q <br /> DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES DISPOSAL r PROP. LINE <br /> FOUNDATION _ AGRICULTURE WELL __ — _ OTHER WEI PITS/SUMPS <br /> INTENDEn USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Intfustr.al f' Open Bottom 11 Manteca Dia. of We'Excavation Dia. of Wen Casing <br /> Domest,c Private Gravel Pack I' Tracy Type of Cosig _ Specifications b <br /> ' Public Other Cella Depth of Grout Seal _--_ _ Type of Grout_.. <br /> Irrigation —Approx.Approx. Depth Eastern Surface Seal Installed by <br /> Repair Work Dw+e T - --- ------ �' r <br /> ytM of Pump ---_ - - - H P- ------------ State Work Done -- -- --Well Destruction ;' Wall Oiarnpwr -__ Seating Material Itop 50.1 <br /> Depth -- Filter Material%Relow 501 <br /> TYPE (4 Sf PT IC WORK NEW INSTALLATION i .' REPAIRIADDITION i I OESTRUCTION� INU septic system permitted d public sewer w <br /> evadable wirhm011 2Met.) <br /> Inat0an•m will sone Residence Cnrnmen 141 tither <br /> Numt>nr of Irving units __— Number of bedrooms <br /> Character of soil to a depth of 3 feet __ -- Water table depth ---_ <br /> SEPTIC TANK TyperMfg -_ Capacity No Compartments <br /> PKG -RFATMENT PLT Method of Disposal <br /> Distance to nearest: Well - _ Foundation _-_ _ Property Line_._ <br /> 1 FACHING LINT No F. Length of linea Total ten, <br /> ,Ith,site _ <br /> FILTER RED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth — ---Site -_--�-- - _--- --Number-- -- ---- --- <br /> SUMPS Distance to merest: well - __-_- Foundation - Property Line <br /> C)ISPOSAL PONDS <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 laws, and <br /> rules anti raqulatrons of the San Joaquin Local Health Dtstnrt <br /> Home Owner of licensed agent's signature certifies the following "I cartdy that in the performance of the work for which this pamst is issued. I shall not <br /> employ any i> son in such manner-,to become subinct to workman's rompensanon 4rwtr of California. 'Contractor's hiring or sub-con•rachng signature <br /> certrhaS the following: "I certify ih;.t in the performance of the work for which rhes perrrut is issued.I shall employ persons subject to workman's comopensa. <br /> Iron lawn ee California" <br /> the aPpt,cant�st cam/'}/o`all required m pec ons Cnmplote drawing on reverse side <br /> Scin Pt / Z—'/./ ✓ ._J."t__ �Title. ti' Date' —5'- -�^Ll--- - --------- _ <br /> FOR DEPARTMENT USE ONLY <br /> Applicahnn ACceptwd by �i_. ,.j-�,.. . 7 - Data c/j_., Area--5�! <br /> 1'n or Grout inspection by --. /.-' -- _— ._—. U.0:• _ finnl Inspection b ."'"� — t�" <br /> r i Y <br /> AddiNnnal Comments <br />