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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> l 1601 E. HAZEL TON AVE., STOCKTON, CA <br /> r Telephone {209} 466-6781, <br /> PERMIT EXPIRES 'I 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 /> i <br /> 'I 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 /> City T Vf Lot Size C'©.1�.�^ PM <br /> OF Job Address � <br /> Address <br /> __ rV Phone D <br /> - • � � <br /> Owner's Name ii i�- V, .•.� �+a L� tea. ,,a - <br /> ��4�2i71Sh �O - - License..No.��SA-- Phone- <br /> Contractor_ " ,.Address_. . .0. <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ <br /> TYPE OF WELL/PUMP: ' <br /> PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER ❑ ''"•: <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> i <br /> FOUNDATION.' ---------­ AGRICI�,LTUEIE WELt OTHER WELL— <br /> INTENDED <br /> INTENDED USE r TYPE OF WELL _ PROBLEM AREA 4CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> I ❑ Industrial ❑ Open Bottom L1 Manteca Dia. of Well Excavation <br /> `- rti It T e of CasingSpecifications > <br /> " ❑rpomestic/Private�_D,Giavel Pack Trace r YP- Type of Grout <br /> k ❑ Public EJOther ❑ Delta E Depth of Grout Seal <br /> �pprox. Depth ❑ Eastern Surface Seal Installed by <br /> ❑ Irrigation j State Work Done N <br /> Repair Work Done D Type of Pump H.P. <br /> I Well Destruction D Well Diameter Sea rig .-Material (top 50'} <br /> I Depth Filler Material {Below <br /> rn t A TYPE OF SEPTIC WORK: NEW INSTAiL,�ATION�❑ ,REPAIR/ADDITION 0 ESTRUCTION l ailablelwithic S n 200 feet.) <br /> d of ubiiC <br /> } -7( n� ; Q <br /> Installation will serve: Resitlerice�� Commercial_ Other- <br /> Y sink �. 1 <br /> ri Number of living units:�.— Number of bedrooms Water tab depth 'I f <br /> Character of soil to a depth of 3 feet: E ., <br /> T e/Mfg tl!1 r.� � �C -CapacLty�_— No. Compartments <br /> t SEPTIC TANK >e Type/Mfg 9 Method of Disposal <br /> PKG. TREATMENT PLT. ❑ i 71 1 f <br /> 1 <br /> Distance to nearest: Well_I t7d Foundation Property Line--?A <br /> -- �� <br /> G No. & Len Length of lines Total length/size <br /> I LEACHING LINE g Property Line <br /> 1 FILTER BED ❑ Distance tolri6arest: Well Foundation '" <br /> "Number <br /> SEEPAGE PITS ■ Depth s' Size f r r <br /> «� ndf At <br /> Property Line� t <br /> SUMPS C1 Distance to nearest: Well- C�.— Fou <br /> DISPOSAL PONDS ❑ <br /> y I hereby certify that I have prepared this application and that the work w0 be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. ;. 1 = <br /> r r . the following: '9 certify that in the performance of the work for which this permit is issued, 1 shall not <br /> Home owner or licensed agent's signaturecertifies <br /> signature <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's lubiect t b orkm niscompensa- <br /> certifies the following: "I certify.that in the,performance of the work for which this permitMis�is�sued,I shall employ persons <br /> tion laws of California." t= ► `` „�,rT . <br /> " The applicant must,call.for ail.required inspections. Complete drawing on reverse side. <br /> , <br /> Title: Date: <br /> 1 Signed . <br /> i FOR DEPARTMENT USE <br /> I w_ <br /> I i � Date % Area <br /> Application Accepted by � ,#- P.i <br /> # incl Inspection by Date <br /> V* <br /> I Pit or Grout Inspection by D Y Y.-. T" F <br /> dditional Comments: <br /> 5tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1.823-7104` ❑ Tracy 835 6385 <br /> Ap ant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i . <br /> FEE CK RECEIVED BY DATE PERMIT''NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> + EH 13-241REV,1/851 `x .+,+ <br /> EH 1428 2 <br />