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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> y 1601 E. HAZELTON 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 end/or install the work herein described.This application is <br /> made in compliance with Sen Jocscut.Z4punty Ordinance No.549 for sewage or No.1862 for wall/pump and the Rules and Regulations of the San:oequln <br /> Local Health District. Y <br /> Jab Addrasa �f Ciry Lot Size ._ PM <br /> / �� .S. � T�NY ��. Phone <br /> Owner's Name <br /> Contract �f -�- ddress �" D License No./ ? ane <br /> TYPE OF WELL/PUMP: N WELL G WELL REPLACEMENT ❑�y DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR % OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> TENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> IDdU.1H8I 15_0p;.Bottom G Manteca Dia.of Well Excavation_ Dia.of Well Casing �. <br /> ❑ Domestic/Private G Gravel Pack C Tracy Type of Casing Specifications <br /> ❑ Public ❑Other G Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation /�4pprox. Depth L. E stem SuQ�e Seal Installed by <br /> Repair Work Doyle La/ Type of Pump _:; , H.P. `"'S State Work Done <br /> Well Destruction Cl Well Diameter Sealing Material(top 501 <br /> Depth. Filler Material(Below SO1 y <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION G REPAIR/ADDITION G DES ERUCTION ❑ (No septic system permitted if public sewer is .l <br /> availacle within 200 feet.) .a <br /> I Installation will serve: Residence_ Commercial_ Other <br /> Number.of living units:_ Number of bedrooms r, <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg CapacityNo.Compartments �f <br /> PKG.TREATMENT PLT.G Method of Disposal <br /> Distance to nearest: Well _ Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED C Distance Eo nearest: Well Foundation Property Line <br /> Ci <br /> SEEPAGE PITS ❑ Depth Size _ Wrmber <br /> SUMPS C Distance to nearest: Well_ Foundation_ Property Line <br /> DISPOSAL PONDS C <br /> I hereby cert' ave prepared this application and that the work will he done in accordance with San Joaquin county ordinances,state laws,and <br /> rules en uletir.s of San Joaquin Local Health District. <br /> Homo weer or licensed age is signeturs certifies she following: 'I certify that in the performance of the work for which this permit is issued,I shall not <br /> amp y any parson in such nner as to become subje workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> ce les the following:"I cert that in the o he work or which this permit is:ssued,I shall employ persons subject to workman's compansa- <br /> tio laws o1 Califon .- <br /> T applicant u all r ire omplote awing on re r skis. <br /> Sign Title: �Date: _ <br /> r ,f-71 FOR DEPARTMENT USE ONLY / <br /> Application Accepted by \C ' ML/L- — Date �1 Area_ 06 X <br /> Pit or Groul Inspection by Date _ Final Inspaction by <br /> Additional Comments: <br /> G SO, 4&5.6787 C Lodi369-3621 Manteca 823-7104 _ Tracy 835-M <br /> Applicant- Return all copies to: Envirm. ,enial a Ith PerMt/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASN RECEIVED BY I DATE I PERMIT NO. <br /> ILi<J <br /> • EM 131.I9f Y. •lJ1r/�� i <br /> Ea 1LA Y O <br /> 7 <br />