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t <br /> APPLICATION FOR PERMIT ` <br /> q3 <br /> SAN �OAQCi?; LOCAL",ncA�TH DISTRICT <br /> PERh1I7 N0. <br /> 1601 F. HAZELTON AVE., STOCKTON, CA l <br /> Telephone (209) 466-6781f ,fi DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM 0.47E ISSUED <br /> (Complete in Triplicate) <br /> st <br /> or <br /> r in <br /> Application is hereby made to the <br /> San <br /> inJoaquin <br /> campliapcelwHthlSanOJeaquin for County p0 dinancceermit to cNfl. 549tfordsewage.orlNo. 1862the w rforewell/pump <br /> described. This application is made <br /> "and the Rules and Regulations of the San ,loaauin Loca'A alth District. <br /> aJl Subdi ' on Name <br /> h�Jo'b Address Phone <br /> i Address <br /> i0wner's Name J�?� Q Phone -� <br /> i icense No. ,F- <br /> lContractor's Name <br /> NEY "r' DESTRUCTION <br /> . TYPE OF WELL/PUMP WORK: WELL REPLRCEMEN7 [] U <br /> SYSTEM REPAIR ❑ OTHER U <br /> PUMP'INSTALLATIONI DISPOSAL FLO, PROP. LINE <br /> SEWER LINES <br /> DISTANCE TO NEAREST: SEPTIC TANK SEOTHER_WELL-__,__,---PITS/SUMPS <br /> .,. <br /> FOUNDATION AGRICULTURE WELL <br /> IR CONSTRUCTION SPECIFICAT10N5 <br /> iNTENDFO USE TYPE OF WELL PROBLEM AREA <br /> Len Bottom []Manteca Dia. of Well Excavation <br /> Industrial Dia. of Well Casing <br /> ! <br /> "i,BSmestic/Private ❑ Gravel Pack [f Tracy <br /> Public [l Other Delta Type of CasingOn,— <br /> LJ Irrigation <br /> Approx. gtern Specifications --� <br /> Depth Depth of Grout Seal <br /> F-ICathodic Protection �a <br /> Geophysical Type of Grout <br /> Other Surface.Seal Installed by <br /> State Work Oone <br /> � 'Repair Work Done � Type of Pump �! ,_ g "- <br /> Sealin Material (top 50') <br /> :Well Destruction U Well Diameter Filler Material (Below 50') <br /> Depth - <br /> REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LI available within 200 feet.) -,-_ <br /> Installation will serve: Residence _ Commercial Other <br /> Number of bedrooms Lot size ___� -� <br /> Number of living units: Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK Ij i Type/Mfg Capacity Method of Disposal <br /> PKG. TREATMENT PLT. Type/Mfg Foundation Property Line <br /> SEWAGE SYSTEM Distance to nearest: Well ----- <br /> DESTRUCTION Total length/size <br /> LEACHING LINE U No. & Length of lines <br /> Foundation PropertyYL;n�».��—,�,.,;---:..�.,.�".`"""e"' <br /> FILTER BED ❑ r Distance to nearest: Well --��-— <br /> ..� A Size Number <br /> SEEPAGE PITS Depth ��� Property Line <br /> Foundation <br /> SUMPS LI Distance to nearest: Well <br /> DISPOSAL PONDS ED <br /> Irhereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county <br /> "I certify that in the performance of the work for which this <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health in the . <br /> Home owner or licensed agent's signature certifies the following: <br /> permit is issued, I shall not employ any person in such manner as`to become subject,to workman compensation laws of Californiaic <br /> ! <br /> Contractor's hiring or'sub-contracting signature certifies �slccompensationrlaws oftify aCalifornit in the aerformance of the work for which <br /> Contra persons subject to workman <br /> this permit is issued, I shall emp y p ections. Complete dr ng on everse side. ✓,�� <br /> The applica t call for al quit iusp Date: <br /> Title: <br /> f Signed X <br /> 0 PARTMENT USE ONLY � � Stk 466-6781 <br /> Area <br /> App ication Accepted'by � � "� Lodi 369-3621 <br /> Additional Comments: D to El Manteca B23-7104 <br /> Pit or Grout Inspection b ❑ Tracy 835-6385 <br /> Date <br /> Final Inspection by <br /> 2009, St k., CR 95201 <br /> Applicant - Return all copies o: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox PERMIT N0. <br /> AMOUNT REMITTED RECEIVED BY DATE <br /> FEE BASE AMOUNT DUE f �� � <br /> INFO o l -� <br /> � 10/82 500 <br /> FH 13-24 REV. 10182 . <br /> 14-26 J <br />