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if <br /> i <br /> APPLICATION FOR PERMIT I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ���1� F 1601 E. HAZELTON AVE., STOCKTON, CA'to i <br /> p.G Teiephane (209) 466-6781 <br /> fit 1Ct3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> t � <br /> Application is he eby mad ` I� �tfCrhoaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance � n County Ordinance No.549 for sewage or No. 1B62 for well/pump and the Rules and Regulations of the San Joaquin i <br /> Local Health,Q�?R <br /> 1�?- \� � ^` <br /> Job Address �f /` /[ j w' `� z�AY, -- City Lot Size PM <br /> i <br /> Owner's Name Address Phone t <br /> Contractor AddressOZ� e No. Phone <br /> 1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION { <br /> PUMP INSTALLATION ❑ SYSTEM.REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _N_—'�Q/ SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELLT // PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private= .Gravel Pack. Tracy Type of Casing &4 OCC Specifications <br /> Public ❑ OtherI F1 Delta Depth of Grout Seal Ty a of Grout 4"� <br /> d i Irrigation _..Approxi: Depth l 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material Itop 501 <br /> Depths Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEIN INSTALLATION I l REPAIR/ADDiTION I I DESTRUCTION I I (No septic system permitted if public sewer is 1 <br /> t available within 200 feet.) C <br /> Installation will serve: Residence—4 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 EJType/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well,— Foundation Property.Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distancetonearest: Well Foundation Property Line <br /> i <br /> I <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS El Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joa uih county ordin8nces, s'taYi3`laws, aid <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 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 /> tion lawsof Cali rnia." <br /> The appl st tali for all require spections. Co plete drawinre a se s' _ <br /> Signed X Title: Date: <br /> R DEPA MENT USE ONLY <br /> Application Accepted by JJ Date' Area 014 <br /> �l <br /> Pito Gra I pectin by Date Final Inspectio by Date / <br /> � l <br /> Additional o mans.�� <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 C1 Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- tum all copie to: EnvironVenta Health Perm'Se ices 1601 elton Ave., P.D. Box 2009, Stk., CA 95201 <br /> ��r� A' <br /> I FEE <br /> E INFO AMOUNT DUE AMOUNT REMITTED �CJASH RECEIVED BY �j DATE q PERMIT ND. <br /> IE +.EHr/nsl fQ� ¢ 1 d5 (��I <br /> 13-241REV. ("���1 <br /> EH 14-211 <br /> i <br />