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APPLICATION FOR PERMIT <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 4 1601 E. HAZEL i ON AVE.; STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> iComplete 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 /> made in compliance with.San Joaquin County Ordinance No.549 for sewage or No. 1862 far well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> l <br /> k Job Address w.-� City Lot Size PM <br /> I � � <br /> Owner's Nam Address co.) s' `�-�'' a Phone <br /> PL C1 L <br /> w � fwd- `' � r 4/� � !. O( <br /> Contractor € Address 7 License No.7 ZOY Phone <br /> t TYPE OF WELL/PUMP: NEW WELL ❑ " WEL=L REPLACEMENT/❑ _DESTRUCTION-8 -µ_r" <br /> t PUMP INSTALLATION ❑ SYSTEM REPAIR❑ OTHER ❑ w <br /> f DISTANCE TO NEAREST: SEPTIC TA!NK'`��� SEWER LINES DISPOSAL FLD: PROP. LINE <br /> f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE Y''i TYPE;OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 1;El,Open.Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br />' <br /> Ll Domestic/Private R❑ Gra el Pack ❑ Tracy Type of Casing Specifications <br />` ❑ Public ❑ Other ❑ Delta Depth of-Grout Seal Type of Grout <br /> i ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by l4 <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done lY <br /> Well Destruction'', ❑ . WeIF i)iar�eterW. Sealing Material (top 50') 9 <br /> Depth ?� �"'""�-= Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION. - REPAIR/•ADDITION>O " DESTRUCTION-B•(No septic-system permitted if•public sewer is <br /> t j _ available within 200.feet.I, <br /> iInstallation will serve: :Residen... ce���Corrimercial_ Other <br /> SNuriber'of living units: Nsumber of bedrooms_ r� <br /> Character,of soil to a depthh f 3 feeA <br /> t: mQ� Water table depth" <br /> SEPTIC TANK ® Type/Mfg APC CAfi.'r L2ri46oilefA Capacity (i0 No. Compartments <br /> PKG. TREATMENT PLT, ❑ Method of Disrosal . <br /> ' :Y `�Distance to nearest: Well t_Ve Foundation ld Property Line �O E <br /> N, j <br /> LEACHING LINE L9YNo. &Length of lines Total length/size 4. <br /> FILTER BED ❑ Distance"to nearest: Well i,3D Foundation /4 Property Line i <br /> SEEPAGE PITS Depth ' " .Size T Number t <br /> l ! k 7 <br /> SUMPS ElDistance tolnearest:z--�lNell=:��-FouLine � <br /> DISPOSAL PONDS ❑ <br /> k 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. t <br /> Houle 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 laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the�performance of the work for whick this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion <br /> tion laws of Califor ia."r <br /> t., The applicant st all f all re ed inspections. Complete drawing on reverse side.'• F <br /> Signed Title: Date: <br /> r i FOR DEPARTMENT USE ONLY <br /> I Application Accepted by Data r� - �A Area <br /> . Pit or Grout Inspection by Date 1'5r-74 Final Inspection b t Date <br /> Additional Comments: j <br /> ❑ Stk 466-6781 : ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED CASH., RECEIVED BY DATE PERMIT'NO.' <br /> + EH 13-24(REV.t/a5) <br /> EH 14-28 © + �•� ( b� � ��Z7 <br />