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W J is,43 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN-LOCAL'HEALTH DISTRICT <br /> 1601 E. HAZEL TON AVE , STOCKTON, CA <br /> 1. -T-e <br /> Aphdri,§�469) 466-6781 <br /> IJ PERMIT EXPIRESA:YEAR FROM DATE ISSUED' <br /> (Complete ill Triplicate}` <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 Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> irK <br /> ddre J <br /> Job A <br /> �bize PM <br /> '4 <br /> Owner's Na ddress Phone <br /> Contractor IQ Add}ss �Phone <br /> TYPE OF LL/PUMP: NEW WELL 0 WELL REPLACEWENT'M —DESTRUCTION' ❑ <br /> PUMP INSTALLATION 0SYSTEM REPAIR L1 OTHER E <br /> --' <br /> DISTANCE i'o�,,'-NEAREST: SEPTIC TANK SEWER LINES — DISPOSAL FILD. <br /> I I — PROP. LINE <br /> FOUNDATION AGRICULTURE WELL — OTHER WELL PITS/SUMPS <br /> INTENDED U E TYPE OF WELL 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> . <br /> 0 Industrial El Open Bottom E) Manteca Dia. of Well Excavation Dia. of Well Casing <br /> P-6cimestic/Private El Gravel Pack El Tracy''. Type of Casing Specifications <br /> 171 Public 0 Other EI Delta -Depth of Grout Seal Type of Grout <br /> Ll Irrigation ---Approx. Depth E3 Eastern Surface Seal Installed by <br /> Repair Work Done 13 Type of Pum: H P. State Work Don, <br /> ! 6F <br /> ❑ Well Diameter 4z (I/ <br /> Well Destruction <br /> Sealing Material (tap 50'� <br /> Depth '(Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIR',IADDITION El DESTRUCTION El (No septic system permitted if public sewer is <br /> I - I <br /> 7 J available within 200 feet.l <br /> Installation will serve: Residence Commercial i ether <br /> Number of living units:— Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 17 Type/Mfg No. Compartments <br /> I — Capacity <br /> PKG. TREATMENT PILT, El- s < Method of Disposal <br /> Ilk Distance to nearest: Well Foundation <br /> Property Line <br /> V <br /> LEACHING LINE Ll No. & Length of lines 'P_ Total length/siz <br /> FILTER BED El Distance to nearest: Well (j Foundation Property Line <br /> SEEPAGE PITS 0 Depth t -Size Number <br /> SUMPS Distance to nearest: Well Foundation— Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that I hive-prepared t"his 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. _41 <br /> —Home owner-.or.-ficensud-ag6-rie.4-94§MYurecerti4rigs'fKef6ili5'wing: "I certify that in the performance of the Work.for which this permit is issued, I shall no.t <br /> employ any p in suc nner as to co a sub' ct to�workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifiest follo"Wing:-Ice fythat inthe of the work for which this permit is issued, I shall employ pePsons subject to workman's compensa- <br /> tion la of Californi <br /> The a 1110ahtlm all req plete drawing on se s'd139, 7 <br /> Sign6d Title- <br /> Date.— <br /> OF <br /> IFOR DEPARTMENT USE ONLY <br /> Application Accepted ed by DateArea <br /> Pit w-Brout-InspeGtion byV C <br /> Date Final Inspection'bylDate <br /> �tr fT <br /> I Additional Comments: 01Z I <br /> 0 Stk 466-6781 0 Lodi 369-346211 11 Mantecil 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.,,CA4520i__-�_� "T! <br /> kAj <br /> FEE AMOUNT DUE AMOUNT REMITTED CK* <br /> INFO CASH RECEIVED BY -DATE i�-PERMIT';N6. <br /> +Ek 13-24(REV.1/8 5) lk5-4 5-7j <br /> rH 14-26 j <br />