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APPLICATION FOR PERMIT <br /> SAN JOAQUIN'LOCAL HEALTH DISTRICT <br /> ux vp:' -t,ze <br /> 1601 E. HAZEL—i ON AVE., STOCKTON, CA <br /> Teleph_o'niii (209) 466-6781 <br /> PERMIT EXPIRES'I'YE ARFROM-DATE ISSUED,` <br /> . Triplicate )- <br /> (Complete in Triplitate) <br /> bnn-,qi <br /> Application ppl'ication is hereby made to the San-Joaquin Local Health District for a permit to construct and/or install the work herein described TMs application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the R Lilies and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 'City Lot Size PM, <br /> V <br /> Owner's Name J9A2k_e_, Address -_S_.a_4ff�e Phone/ -5 <br /> fPhone — <br /> Address -Z30! License N o C) <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL E3 WELL REPLACEMENT O. DESTRUCTION 0 <br /> PUMP INSTALLATION 0 A SYSTEM_REPAI R-�.-[D OTHER 11 <br /> DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES\ DISPOSAL FLO.— PROP. LINE <br /> FOUNDATION AGRICULTURE WELL — OTHER WELL PITS/SUMPS SIN <br /> .�_ �INTENDED_USE.s TYPE OFAWELL PROBLEM AREA,—CONSTRUCTION spEci F-I CATIONS <br /> 11 trididstri6l l Ll Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 0 Domestic/Private El Gravel Pack 0 Tracy' Type of Casing Specifications <br /> D Pub_ 0 Other Ll Delta Depth-&-Grout-Seal Type of Groiit'_�, <br /> Ll Irrigation --Appro'x. Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State:Work Done <br /> r <br /> Well Destruction 0 WL 'e-ll"Diamete'r Sealing Material (top 501 <br /> Depth Filler Material (Below 50'. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION.0 REPAIR/ADDITION DESTRUCTION Ll (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Comme,.,a Other <br /> Number of living units; Number of bedrooms <br /> Character of soil to a depth of 3 feet: " I Water table depth <br /> SEPTIC TANK 0 ,Type/Mfg -eapacity No. Coimpaftmontst,- <br /> PK6. TREATMENT PLT. E Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> Lai <br /> LEACHING LINE No. & Length of lines Total length/size <br /> FILTER BED [I ;Distance to nearest: Well Foundation°_ Property Line <br /> : SEEPAGE PITS CD 'Depth Number <br /> SUMPS a 7 <br /> J Distance-to nearest: Well� Foundation /o/ Property Line <br /> DISPOSAL PONDS E3 <br /> 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-Hbalth District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that�,,Jthe performan6e of the work for which this permit is issued, I shall:no't <br /> employ any person in such manner is to.become subject to workman's compensa [on laws of California."Contractor's hiring or sub-contracting signature <br /> r <br /> certifies the following: "I cerVythatin the� perf6rmance of the work for which thi_sp'e_rm_rt is sHaill employ persons subject to <br /> of California." <br /> The applic6nt must call f all required inspections. Complete drawing on rover side. <br /> or <br /> IfGl � - <br /> Signed Title: 7 <br /> 4 <br /> OR DEP RTME T S ONLY' <br /> Dae <br /> Application Accepted <br /> Pit or Grout Inspection by Date 7,�ZFinal Inspection by <br /> Additional Comments: <br /> 0 Stk 466-6781 0 Lodi 369-3621 0 Manteca 823-7104 LJ Tracy 83x5-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601'E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT A�.S*H RECEIVED BY DATE- PERMIT NO. <br /> C <br /> INFO <br /> +EH 13-74)REV.1/85Y Z-7 <br /> EK 4-26 <br />