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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL.HEALTH DISTRICT <br /> 1601 E. HAZE,--16N AVE.,"-STOCKTON, CA <br /> Telephone (209) 466-V81 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (complete in Triplicate) <br /> th'. %1 vlcifJ33-, % <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 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. ',P,; <br /> '7LIi 1� /�o X 67463 'PM <br /> Job Address A71 Size <br /> Owner's Name &I ?0J; Address 0-0 3VJ 14 Phone -:-092;2 , <br /> Contractor Address Witense No. Phone <br /> TYPE OF WELL/PUMP: U NEW WELL WELL REPLACEMMT Ll DESTRUCTION 0 <br /> PUMP;INSTALLATION El SYSTEM REPAIR El OTHER LI <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — DISPOSAL FLD.Z69 PROP. LINE <br /> FOUNDATiON AGRICULTURE WELL — OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial 0 Open Bottom El Manteca Dia. of Well Excavation 27 Dia. of Well Casing 6 j <br /> Domestic/Private XGravel Pack XTracy Type of Casing Ins <br /> 0 Public Ll Other Ll Delta Depth of Grout Seal Type of Grout <br /> 0 Irrigation ---Approx. Depth El Eastern Surface Seal Installed by <br /> RepairWork Done LJ Type of Pump H.P. ' <br /> State Work Done <br /> Well Destruction I] Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ED REPAIR/ADDITION ID DESTRUCTION 71 (No septic system permitted if public sewer i; <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: — Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK LJ Type/Mfg CapacityNo..Compartments <br /> PKG. TREATMENT PLT. F7 ;Method of Disposal. <br /> Distance to nearest: Well Foundation Property Line ev <br /> LEACHING LINE 0 No.'& Length of lines'' Total length/size <br /> FILTER BED El Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 171 Depth Size <br /> I — Number <br /> SUMPS ID Distance to nearest: Well Foundation Property Line <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 ordinances, state laws, and J, <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify thk in the performance of the work for which this permit I.s 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 which this permit is issued, I shall employ persons subject to workman's compensa <br /> lion laws of Clifornia." <br /> The ap"' kust call for all;J <br /> it inspections. Co plate drawing on v rse 1 e. <br /> Signed A6 AU J J <br /> Title: Date:M o2 <br /> �FOR DEP T ENT me,"n"4,4r <br /> 4u, ENT USE ONLY <br /> Application Accepted by Dais' Area <br /> Pit or Grout inspection by Date I <br /> Date IT al Inspection <br /> Additional Comments: 7. <br /> 0 Stk 466-6781 0 Lodi 369-3621 0 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 /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> + EH 3-24(REV.I/a 5) Lit <br /> 14-26 q3 Iq 97� <br /> EM I <br />