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.► APPLICATION FOR PERMIT w..� <br /> SAN JOACIUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELT ON AVE., STOCKTON, CA <br /> Telephone 12091 466-67$1 <br /> iL <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> w Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Q <br /> i /�� �, _ • City Lot Size aeltzIt'llPM <br /> 6W Job Address <br /> Address L` Phone w 1 <br /> 16-0 Owners Name N 7 � Ptane1)e, <br /> Contract r: Address License No.a 2 <br /> �6 <br /> TYPE OF WELL/PUMP: NEW WELL Ll WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> 6.0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 6.0 ❑ Industnal LDOpen Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing _T Specifications w <br /> f`1 Public f=1 Other ❑ Delta Depth of Grout Sea$ Type of Grout - \ <br /> 6d 1 1 Irrigation —.Approx. Depth l I Eastern Surface Sea! Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Weil Diameter Sealing Material (top 56'1 - <br /> Depth Filler Material 16olow 501 <br /> r.v <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1 I DESTRUCTION I S (No septic system permitted if public sewer is <br /> available within 206 feet.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: - _/- Number of b r ams ! <br /> Character of soil to a depth of 3 feel: _—Water table depth T <br /> SEPTIC TANK f(Td' Type/Mfg Capacity_ �� No- Compartments <br /> PKG. TREATMENT PLT. El / 6 Method of Disposal <br /> Distance to nearest: W eA Foundation_ !D Property Line <br /> LEACHING LINE 1J*- No- & Length of lines d Total length/size <br /> 1V.r / <br /> FILTER BED ❑ Distance to nearest: Well _ 1640 Foundation�(� Property Line 115­41 <br /> SEEPAGE PITS Ibl"Depth _ _Size - Number <br /> SUMPS Ll Distance to nearest: Well_ - Foundation /1 Property Line_737 <br /> DISPOSAL PONDS El <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 and regulations of the San Joaquin Locat Health District. <br /> rr Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mus 111 all?reqtndpections. Complete drawing on reverse side. `� <br /> Signed x Title: Date: ,_-_q d J7 <br /> FOR DEPARTMENT USE ONLY <br /> �... Date "' Area <br /> Application Accepted by _ <br /> t�� - <br /> ()P1or Grout Inspection by Date 7Fina! Inspection by <br /> 1,a <br /> Additional Comments: <br /> 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 635-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave-, P.O. Box 2009, Sik., CA 95201 <br /> v <br /> FEE AMOUNT DUE AMOUNT REMCK INFO CASH_ EO RECEIVED BY DATE PERMIT NO. <br /> + <br /> EH <br /> t3-24 TREY.SiH51 <br /> w EH 14-26 r <br />