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-t APPLICATION FOR PERMIT ,/ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ��% <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> \� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �,v- G�' \QX\ <br /> 4i cP <br /> (Complete in Triplicate) <br /> Q(I;Appl <br /> leby madu to the San Joaquin Local Health District for a permit to construct and/orinstall the work herein kiriccribed. �llcation is <br /> with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and RegulationE��'San Joaquin .r <br /> Health District. O <br /> Job Address ��li�yj,_�V�t{- �y>1 1 / �►S c,y1q I City �"����Lot Size ` PM <br /> Owner's Name C i C 99 <br /> Jy-ol—? Address �;s EJ_por D S� _ Phone +� <br /> Contractor (Sjtic����t_. N G. Address C s F/'CM onT CH 4Yr38 <br /> ---- y�6 License No.2f�3_�_Phone(91-s)(n3 -o <br /> TYPE OF WELL/PUMP: NEW WELL 1.7 WELL REPLACEMENT 17 DESTRUCTION C7 I SOI p <br /> PUMP INSTALLATION C) SYSTEM REPAIR I I OTHER In 170rf✓1'f . <br /> DISTANCE TO NEAREST: SEPTIC TANK -- __— SEWER LINESDISPOSAL FLO.__-_"_ PROP. LINE _ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n I I Industrial [J Open Bottom CJ Manteca Dia. of Well Excavation SS,�, <br /> !ti _: Dia. of Well Casing <br /> I I Domestic/Private ❑ Gravel Pack O Tracy Type of Casing_---______ <br /> r ' 9---_..__--__.__.__ Specifications _ <br /> I I Public K�,O.,pthre�r Q0r1N,y' 0„� Delta Depth of Grout Seal _ o Type of Grout .� <br /> R 411011 <br /> R Irrigation o�( .2pprox. Depth LI Eastern Surface Seal Installed by �OK ^4L]`O/ <br /> o . "Oork, Le s <br /> epaH ork one ❑ Type of Pump __ H.P. _ State Work Ione_Well Destruction I-1 Well Diameter ------ Seating Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEP WORK: NEW INSTALLATION 1:1 REPAIR/ADDITION U DESTRUCTION 11 1 ptic system permitted if public sewer is <br /> Installation will se e: Residence_ Commercial _"_ Other available within 200 feet.)_ <br /> Number of living unit . _. "_ Number of bedrooms <br /> Character of soil to a de of 3 feet: r <br /> -- - ---- ----- -- _..__._.._Water table depth <br /> SEPTIC TANK I I /Mfg <br /> Capacity---_.,___PKG. TREATMENT PLT. II -- - <br /> . No. Compartments <br /> Method of Disposal \ <br /> Distance nearest: Well Foundation Property Line <br /> LEACHING LINE I I No. 8 Length of it Total length/ <br /> FILTER BED I I Distance to n est: ell . Foundation <br /> -- Pro y Lin <br /> -- ----- — <br /> SEEPAGE PITS - �- - - -� --- <br /> I De tt _ __ -_ -_Size _ Number <br /> SUMPS ----------- <br /> I I ance to nearest: Well _ oundation ______ Property Line <br /> DISPOSAL PONDS I 1 --- <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 Local Health District. <br /> 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, I shall not <br /> employ any person in such manner as to become subject to workman's compensation <br /> certifies the following: "I certify that i e rformance of the work for which permit is issueof d, I shall employ rector's hiring or csub-contracting signature <br /> tion laws of C rnia." p P Y Persons subject to workman's compensa- <br /> tion <br /> app , w st call for all required - spections. Complete drawing oon7 reverse <br /> side. <br /> Signed /% nby <br /> .GiCiTitle:FOR DEPARTMENT USE ONLY Application Acce ___ Date-± C <br /> Area <br /> Pit or Grout Inspection by AAditional Comments: Date Final Inspection by11 Stk 466-6781 l_1 Lodi 369-3621 C7 Manteca 823-7104 L7Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUTED Q- <br /> INFO <br /> NT DUE AMOUNT REMIT-TED <br /> ` CASH RECEIVED BY ATE PERMIT'NO. <br /> • EH 137 (REV.1 1”5) /� 7/ <br /> EH I4.26 c/ �I <br />