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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOClCTON, CA <br /> Telephone (209) 466-6781 , • �t,: h <br /> PERMMIT EXPIRES 1 YEAR FROM DATE ISSUED r -,;•; fr ?+ 4 <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 /> nty Ordinance No.549 for sewage Or No.lau for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compdance with San Joaquin Cou <br /> r <br /> Local Health District. . r„ Y �—�-, ,, �, i .. <br /> / y C'rry Lot Size PM <br /> Sob Address J <br /> Address - -�.., Phone` <br /> Owner's <br /> y c License No. �` D Phone <br /> Contractor's Name DESTRUCTION ❑ f <br /> -TYPE OF WELL/PUMP: NEW WELL ❑ 'WELL REPLACEMrAC <br /> C <br /> SYSTEM RE� OTHER C <br /> PUMP INSTAL ❑ , <br /> SEWER LIES '" DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL—PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> 3` <br /> INTENDED USE 11�,/TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS c'Dia of Well Casing <br /> C Industrial ! G Open Bottom C Manteca l Dia. of Well Excavation._ <br /> t ii �'?:�i5pecifications <br /> ❑ Domestic/Private rJ Gravel'Pacic C Tracy p Type of Casing__ _ <br /> lJ ,3V 1 "pTlipe of Grout— <br /> Depth <br /> ❑ Public C Other uJ ❑ Delta Depth of Grout Seal} `� <br /> ❑ Iriigation ---Approx. Dap�f "❑ Eastern°,.0 1 'Surfave Seat Installed by <br /> Repair Work Done C Type of Pump1 n H•P. J State Work Done <br /> i. , . *�. z <br /> Y' j <br /> Well Destruction ❑ Well Diameter SealingMaterial'top 50t" <br /> DepthFiiler.-Material4sebw 501 w._ <br /> TYPE OF SEPTIC WORK: NEW fNSTALLATION REPAIR/ADDITION + DESTRUCTION'Cl�{No septic system:permitted if public sewer is <br /> j available within 200 fog <br /> Installation will serve: Residence Commercial�y'yOther l"�y` 1 r <br /> Number of Living units: Number of bedrooms�--� f V�� >- -. <br /> =S �t:. Wat'ertable depth <br /> Character of soil to a depth of 3 feet:. No Comprtments <br /> Y, Type/Mfg <br /> SEPTIC TANK _? s,-- �„ Pacity� $ Ur a! " t i <br /> Method of Disposal <br /> PKG.TREATMENT PLT.❑ �-7 1 �'` pro a line_s7 =- <br /> Distance to nearest: Well !S Foundation P t <br /> +7 _Q �" ! Tota I gth/size Lj <br /> LEACHING LINE � No. &Length of fines i <br /> i' FILTER BED C Distance to nearest:` Wel' Foundation Property Una <br /> f f <br /> ri Size 1 Number <br /> SEEPAGE PITS E, Depth / Property Line" <br /> SUMPS ❑ Distance to nearest-4 <br /> —"�Ne11"-- "foundation P rtY <br /> E DISPOSAL PONDS ❑ <br /> 1 hereby certify that 1 have prepared this application and that the work will be done iA accordance with San Joaquin county ordinances,state laws, and <br /> rules and regulations of the San..Joaquin Local Health.Df6lk4inj: ­I istnct:� work for <br /> Home owner or licensed agents signature <br /> work <br /> subject too workman's compensation lr he aws of California.nce of e Contractor's'hiring or sub-contracting signature <br /> employ any person in such manner persons subject to workman's comp nsa- <br /> certifies the following,"1 certify that in.the performance of the work for which this permit is issued,I shell employ p ; <br /> € tTon laws of Californi <br /> C for-a ,Jquiren ctns. Complete drawing on reverse side. <br /> The applicant of <br /> Date: Q <br /> Signed Title E <br /> FOR DEPARTMENT USE ONLY <br /> Area <br /> Date r <br /> Application Accepted by tri <br /> { Y' i Final Inspection by Date <br /> Pit or Grout inspection by Da <br /> f Additional Comments: r` U�CI �1 <br /> 4 G Stk q&6�i781 ❑ Lodi 369-3K1 ❑ Manteca 823-710$J ❑Tey �M <br /> � ��4� <br /> Applicant-Return:dll copies to: Environmental Health PermitlSetvices 1601 E. Hazekon Ave.;.P.O. ox Stk., CA 9524 1 <br /> i CK n��io <br /> PFEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE <br /> -144�7F -7 <br /> . INFO <br /> 1' + ex tau IREv.to+asl �t I <br /> EA u-2s <br />