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• - APPLICATION FOR,PERMIT k <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE:.TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR-rFROM DATE ISSUED <br /> (Complete_in Triplicate) <br /> 2;"z'.^ 1 <br /> Health <br /> Application is hereby Rh Sancation is <br /> oJoaqu the n County Ordinance lNo.District549 for sewage or'No. 1862 for well/pump t to construct and/or install <br /> nd the Rules and IR Regulations of he San l Joaquin I <br /> made in compliance w <br /> Local Health <br /> Lot Size PM l <br /> Job AddressDistrict. 3 � .. <br /> one <br /> Owner's Namen4,111111111:11111 111",", 7 -e4 Address c h <br /> Phone 69 <br /> ,4�11se No. c.l <br /> Contractor's Name WELL REPLACEMENT El DESTRUCTION ❑ t <br /> TYPE OF WELL/PUMP: NEW WELL ❑ OTHER El , <br /> PUMP INSTALLATION C1 DISPOSAL <br /> REPAIR 1-1 <br /> p1SPOSAL FLD. PROP. LINE �~ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> l <br /> I• <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> FOUNDATION ��-- <br /> t ' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> Dia._of Well Excavation <br />� <br /> Industrial ❑-Open Bottom-���"❑-Manteca,�-- Specifications <br /> ❑ Tracy Type of Casing <br /> El Domestic/Private ❑ Gravel Pack %Depth of:Grouf Seal. Type of Grout ` <br /> �.Other, i El Dela, . � _ ` 11! <br /> ❑ Public Surface SealInsll <br /> ' taed by- <br /> E3 <br /> y❑ Irrigation <br /> __�Approx.:_Depth:W_❑Eastern H.P. State Work Done W <br /> Repair Work Done ❑ Type of Pump Sealing Material itop 50'l <br /> a Well Destruction [3 Well Diameter <br /> Depth t Filler Material (Below 50'1 l- <br /> k TYPE OF SEPTIC WORK: NEW INSTALLATION Q REPAIR/ADDITION ❑ DESTRUCTION ❑ availableiwt in 200 fec system ettted if public sewer is <br /> Installation will serve: Residence Commercial— Other. t"„r <br /> Number of living units: Number of bedroomsWafer fable depth <br /> Character of soil to a depth of 3 feet: 4'MCapacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg LMethod of Disposal (O <br /> f t <br /> f PKG. TREATMENT PLT. F7Foundation. <br /> Property Line <br /> Distance to nearest: Well <br /> o Total length/size"' <br /> LEACHING LINE � Na. & Length of lines I - _G Property Line <br /> ❑" Distancerto nearest: Well Fouridetiori <br /> ' FILTER BED <br /> SEEPAGE PITS Rf Depth Size � _�, --i <br /> F undation4!��Property Line Z,69-0 <br /> SUMPS ❑ Distance to nearest: Well L L 4 <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordances*;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 signature <br /> shall not <br /> tion <br /> employ any personin such <br /> certify that n the performance he A to wo k f r�wh ch this permit issued,of fI shall employ persons ornia." Contractor's (subject t woeing or �kman'1scompensa <br /> certifies the g _ _1% - ' . <br /> tion laws of California." 6z^ , <br /> The applica ust call for all uired ins ctions. complete drawing on reverse side. ([�� <br /> 30 <br /> d'J�f Date: <br /> Title: <br /> Signed <br /> FORD PARTMENT USE ONLY <br /> Date l Area <br /> Ap kation Accepted by <br /> Gly L� Date Final Inspection by <br /> ,PK or Grout In pection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 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 /> CK RECEIVED BY DATE PERMIT"ND. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> �1/ 'eesS- S <br /> + EH 13.24(REV.10183) <br /> EH 14-28 ' <br />