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1 . APPLICATION FOR PERMIT <br /> l <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> 1 Telephone (209) 466-6781 I <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> 1. <br /> 1 (Complete in Triplicate) application is <br /> nce No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <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 <br /> a fiance with San Joaquin County Ordind l <br /> made in comp •� ,r <br /> Local Health District. r �2 j PM <br /> L Lot Size <br /> city � -. - , <br /> Job Address <br /> Phone <br /> Address <br /> Owner's Name J1 <br /> 133 xS- <br /> 73 f License No.� Phone_ <br /> ms'sf`du Address r <br /> Contractor �J" WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELUP P: e NEW WELL ❑ OTHER ❑ <br /> PUMP INSTALLATION C3 . <br /> SYSTEM REPAIR L1DISPOSALFLD. PROP. LINE <br /> - ` <br /> SEWER LINES --- PITSISUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK --�— AGRICULTURE WELL OTHER WELL <br /> FOUNDATION <br /> INTENDED USE +� i TYPE OF,WELLr PRDSLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> LD, Bottom ❑ Manteca Oia..of Well Excavation <br />� ❑ industrial <br /> Specifications ?' <br /> ❑ Tracy ti'4' TYPe of Casing Type of Grout <br /> ❑ Domestic/Private-� ❑ Gravel Pack a Depth of Grout Seal <br /> ti J Other [I'Delta� <br /> M Public... tSurface Seal Installed by <br /> I ! Irrigation _..APProx. Depth t I Eastern State Work Done— <br /> Type <br /> of Pump ---�- H.P. <br /> Repair Work Done ❑ , Sealing Material (top 50'1 <br /> Well Destruction ❑ Well Diameter __�.�— - <br /> Depth I Filler Material I Below 50') <br /> available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION, REPAIR DD�ITIO4 tj1 DESTRUCTION i I (No septic system permitted if public sewer is <br /> .. y <br /> Installation <br /> -"-Other�—� <br /> ation will serve: Residence O <br /> Number of living units: <br /> _� Num ber.of-bedroomp Water table depth <br /> Character of soil to a depth 00feet: Capacity j__�- No. Compartments <br /> I SEPTIC TANK ,.�'' ❑ TYpe/Mfg Method ofB'STsal <br /> I ! —.Property 1 <br /> PKG.TREATMENT PLT. ❑ j <br /> ` Distance to nearest:'" s Well Foundation 1? <br /> r <br /> T allengthlsize <br /> r ACHIN LI No. & Length of lines �- P� <br /> �E / Foundation Property Line <br /> FILTER BED - ❑ Distance to nearest: Well_lr'� <br /> _umber <br /> I i Depth Size �, <br /> ! SEEPAGE PITS r Foundation--Property Line <br /> I MDISP <br /> t-I Distance to nearest: �. Well" <br /> L PONDS ❑ <br /> l T� I hereby certify that I have prepared this application and that the work will be done.in accorda nth.San Joaquin ceunty ordinances, state laws, an <br /> r..�1k shall not <br /> rules and regulatios.pef mit is issued, <br /> ns of-the San Joaquin Local Health ptricY.' <br /> Home owner or licensed agent's-signature a suthe b to wok man's compensat­I certify that in ion l�s of Califorrnia?"Contractor'sk for 1hir hich ring or tub-contracting lsignaturre <br /> .,` employ any parson in such manner' to ersons subject to workman's compensa <br /> r r certifies the foil g: 'd certify that in the performance of the work for which this permit is issued, I sball,emp Y P <br /> F< <br /> tion laws of'Ca Ifo ia.' «�"�"'.'�~ <br /> r/�} * ` <br /> The applicant u t call r all re wired inspections.-Compiate drawing on revep� _ y <br /> r t pate: <br /> l Title: <br /> Signed X <br /> F R DEPARTMENT USE ONLY r <br /> -- 1` Date Area <br /> Application Accepted byFinal Date <br /> Date nspection y <br /> Pit or Grout Inspection by f � <br /> ❑ Manteca 8237104 a ❑/Tracy 835 5 <br /> Additional Comments: t <br /> Cl Stk 466-6781 ❑ Lodi '369-36211 Stk., CA 95201 <br /> Applicant - Return all copies to: Environmental Health permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Iry <br /> tZiTH4 <br /> RECEIVED BY PERMIT'NO: <br /> FEE AMZaAMOUNT REMITTED <br /> INFO <br /> ♦.EH t3.24IREV.I/H51 - . <br /> EH 1445' <br />