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APPLICATION FOR PERINII <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HP.LEL i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT-EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Apphcaunn is heloby male to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This appllcat"M K <br /> nad+In complla•ce with San Joaquin County Ordinance No 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the Sen JoaOtn^ <br /> Local Health Distric• ++, <br /> City&UV 41�k1 Low S�e�s�— PM 9- <br /> _ _-�-� J� <br /> Job Address ­> ,) .. � �Q�d.t..+1�c<"►'1 A . "s <br /> 1 <br /> C � 7 <br /> < L <br /> -- Phone `_hjls_—b <br /> Owner's Name( Address 3 <br /> 1 Poni <br /> 2dess Liccnsc No. P <br /> Contiicto � <br /> V <br /> (� <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION L1 1 <br /> PUMP INSTALLATION SYSTEM REPAIR I' OTHER ❑ <br /> DISTANCE TO NEST: SEPTIC TANK -__._ __. SEWER LINES DISPOSAL FLD.--_-- PROP. LINE _ <br /> -�-Ppy81(2.ATION __ __ __ AGRICULTURE WELL _—_— OTHER WELL __—_PITS/SUMPS <br /> INTENDED USE TYPE OF WELL BIFMA� CONSTRUCTION SPECIFICATIONS <br /> Industrial Open Bottom i' Manteca �1a-a 11 Excavation Dia. 01 Well CasingDomestic/Private Gravel Pack i Tracy Type of Casing.___- _ Specifications <br /> Public Other Delta Depth of Grout Seal of Grout <br /> Irrigation -Approx. Depth Eastern Surface Seal Installed by -_- -- --- ------ - <br /> Repair Work C`,)ne Type of Pum H.P. __ State Work Done __-_ ----Well Destruction Well Diameter __ Sealing Material(top 50.1 _-_---_---.—.-------------- -- - <br /> Depth _ Filler Material(P'ilow 501 ___--_--- - --- -- --- --- \ k <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION /✓REPAIR/ADDITION DESTRUCTION (Naolls et system within 200fee <br /> if public sewer is <br /> Installation will serve: Residence _ Commercial __ Other <br /> Number of living units - Number of bedrooms <br /> Character of soil to a depth of 3 feet: / Water table depth <br /> SEPTIC TANK a Type/Mfg _�C K t f CIL fLS.0 tz.,_.____ Capacityj&C10- No. Compartments - <br /> PKG. TREATMENT PLT. I i Method of Disoosal <br /> Distance to nearest: well S� Foundation _LO Property Line <br /> LEACHING LINE ANO. & Length of lines �ys_.�-- 1� Total length/size- <br /> FILTER BED I Distance to nearest: Well_SC` Foundation - __-_ Property Line <br /> SEEPAGE PITS Depth -,_ Size __--_ _._.___-- Number --_----- <br /> SUMPS Distance to nearest: Well__._.__ Foundation _ _- ___ Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared this application and that the work will he done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agents signature certifies The following: "'I certify that in the performance of the work for which this permit is issued, I shall not <br /> come subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> employ any person in such manner as to be <br /> rertlfies the following:"I certify that in the performance of the work for which this permit is issued'.I shall employ rersp s subfect to workman's compen58 <br /> tion laws of California." <br /> The applicant st call to 11 regy red inspections. Complete drawing on rexorse sI e. <br /> Signed X - � _ _Y`�' - Title: - -�'-=-- - - ---- -- - Date:Il LC - <br /> FOR DEPARTMENT USE ONLY <br /> Apphccaattion Accepted by /- Area <br /> Pit of Grout Inspection by Q�J_ Q� Date LFinal Inspection b Oateqff <br /> ' <br /> Additional Comments: ///"`JJI - <br /> Stk 466-6781 L; Lodi 369-3621 C Manteca 823.7104 U Tracy 835 8385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk . CA 95;201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By GATE PERMIT NO. <br /> INFO <br /> FH IJ�N IREV <br /> n `cQ <br /> EH I4 2e - <br />