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APPLICATION''FOR PERMIT <br /> �. . <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT � �;�u <br /> 1601 E. HAZELTON ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> SUN <br /> sE <br />' � . -� .a;:i;�r� • >. (Complete in Triplicate) -"' �� " M t4l <br /> , pplication is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the �aq <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rul a Regulations of the San Joaquin <br /> Local Health Di trrct. <br /> Job Address _ , ��- <br /> -� �;f'Te/U'E Iw City Lot size PM <br /> I1. �jr �,� — Address Phone �7 <br />� Owner's Name _ <br /> .I�' �� p�Phone —r�z <br /> Contractor N5 Address a�r � icense No. <br /> TYPE OF WELbPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ <br /> PUMP INSTALLATION P R,-p,{.,XXjy V6TEM REPAIR ❑ OTHER ❑ O <br /> DISTANCE TO�NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> s <br /> INTENDED�USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial 1N. ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> { T of Casing Specifications <br /> 0omesticlPrivate ❑ Gravel Pack ❑ Tracy Type g T of Grout <br /> 4 ❑ Public ❑ Other El Delta Depth of Grout Seal ype <br /> El Irrigation __Approx. Depth ❑ Eastern Surface Seal Installed by <br /> H P State Work Done <br /> Repair Work Done [D Type of Pump �� <br /> j-ML A&014-7 <br /> Well Destruction Sealing Material [top 5 <br /> n O Well Diameter 0'i <br /> w .!� Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ availabNo lerwithine2W permitted if public sewer is <br /> I <br /> Installation will server Residence— Commercial— Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ �%1 Y Method of Disposal <br /> 'x� <br /> Distance to nearest: Well t Foundation ' Property Line <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines _��� <br /> FILTER BED�� ❑ Distance to nearest: Well '"`Foundation 1 <br /> 1 Property Line <br /> Size I i �? Number <br /> SEEPAGE PITS ❑ Depth . "I <br /> r SUMPS f ❑ Distance to nearest: Well Foundation_ Property Line <br /> ' DISPOSAL PONDS ❑ <br /> i 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. :�1 <br /> f 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 /> r, 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 which this permit is issued,1 shall employ persons subiect to workman's compensa- <br /> 1 <br /> l tion laws of i��California." <br /> The applicant mut all fTQp all re it d inspections. Complete drawing on reverse;id e. / <br /> Title: Date: !rte <br /> { 7.A 7 <br /> Signed i <br /> III FOR DEPARTMENT USE ONLY <br /> } I� Date Are <br /> ApplicationgAccepted b <br /> Pit orGrout Inspection Date Final Inspection by <br /> Date <br /> E nM <br /> Additional Comments: -- --�" <br /> ❑ Stk 6781 Ave., <br /> 835-6385��""� <br /> Applicant Return all copies to: Environmental Health PeimitlSe+vjoe�7160f Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> EE CCK <br /> ASH RECEIVED BY DATE PERMIT"NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> » + EH 13-241REV.7/65] - <br /> EH W28 1 <br />