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" 1 <br /> 1 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> OPY <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 the Rules and Regulations of the San Joaquin <br /> Local.Health District. <br /> Job Address <br /> 7�tQtJ f , City LOD Lot Size �. ) PM <br /> 36 7 <br /> CC r ! ,✓ — Phone <br /> Owner's Name Address <br /> ConlFaclor Address_�_ <br /> �� t-"- License No. Pfione���� �� <br /> ;TYPE OF WELL/PUMP: <br /> - —NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTfON LJ f <br /> •PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER❑ 1 <br /> DISTANCE TO NEAR 166T:_SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> WELL <br /> V OTHER WELL ?ITS/SUMPS <br /> AGRICULTURE WE <br /> FOUNDATION _ F <br /> ;INTENDED USE/ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 1 ❑ Open Bottom 0 Manteca Dia,of Weld`Excavation <br /> Dia of Well Casing <br /> ❑ borrresticlPrivate ❑ Gravel Pack 0 Tracy ? Type of Casing Specifications j <br /> Type of Grout <br /> - � f 1 t.hlicL7 Other (-1 Delta depth of Grout Sea! YPrigation _Approx.,Depth I I Eastern i Suiiace Seal Installed by - <br /> i i State Work Done _ <br /> .,Repair Work Done LJ .Type of Pumi1 <br /> Welt Destruction 1 ❑ Well Diameter i Seiiing Material (lop 501 <br /> I Depth Filler Matenal,IBe" in <br /> TYPE OF SEPTI WORK NEW iNSTALLATION� REPAIRJADDITION { DESTRUCTION l I (No septic system permitted it public sewer is <br /> � ; � �-`r .� " ' availLabte within 2tx1 feet.) j <br /> I stallation wnl-sere Residence Commercial Other <br /> g Number of bedo ms { I �' <br /> Number of IM its) I <br /> 4 Character,of s it to a depth of 3 feet: Water table depth 5 <br /> �` _ No. Compartments l <br /> SEPTIC TANK, pe/Mfg Y pa Ity I <br /> PKG. TREATM T PLT.❑ Method of Disposal <br /> 1 Dista ce to eearest: ell f. Fau _666 L._ Property Line <br /> LE4�CHING LIN Cl' No. & Length of line r Total length/size 's <br /> FILTER BED O Distance to nearest. Well • atron ' r Property Line+ / r /;A L <br /> Qom, N � _ 1 • <br /> SEEPAGE PITS k.i�Depth a r ize umber <br /> SUI, I 0 Distance to nearest: j tlf1e11 ° � �ouLrdation b Propei�y it .� Ste? <br /> I DISPOSAL PONDS ❑ <br /> ordinanizes, stat I )evils, and <br /> I hereby certify tat I have prepared this application�a that this work trill U one iny1accordartce-wrth San Joaquin b <br /> rule and regulat`ons of the San Joaquin Local Heal h Dl1trict. f <br /> Ho a owner or licensed agent's signature certifies the following] "I cerJy-thts -tM; I forUance of the work for wlf&h this permit is issued 'shall not <br /> ' vs of alifornia." Contractee'?-hiring.or sub contractin signature <br /> em loy any persop in.such manner as to become sub Octect to wor man's wmpe�„s�atior a . <br /> certifies the tollowting: '9 certify that in the perfarman a of the w rk for which this Permit is issued,1 shall employ pe ns subect to workman's o_mppeensa- <br /> " tion laws of California. <br /> Theapplicant mus call or II required inspections. Cpmplete d awing n:r verse side. <br /> Title: GC�.f� Date: & <br /> Sig ed , <br /> N FOR:DEPARTMENT USE ONLY CA- 3" <br /> + / — <br /> Area / <br /> Application Accepted b Date c; <br /> Pir Grout Inspection by <br /> Date Final Inspection by Date <br /> Additional Comments: <br /> 0 �tk 466-6781 © Lodi 369-3621 ❑ Manteca ffi3-7104 ❑ Tracy 1335-6385 <br /> Ap icant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O..Box 2009, Stk., CA 95201 <br /> �I i I <br /> AMOUNT DUE AMOUNT REMITTED CASH BECFIVED BY DATE PERMiT'NO. <br /> INFO <br /> ..EH 13-I4 IREV.I/115) 0, ® r <br /> ' EH 1428 P <br />