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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> t' Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) - , <br /> application is <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 /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and R�ulations of the San Joaquin <br /> Local Health District. <br /> 7 7� City tat Size PM <br /> Job Address ?7741 <br /> 1' Phone <br /> Address <br /> Owner's Name � -,. _�•� ��--�------�/ <br /> � / Phone <br /> �U� - _ Address I License No <br /> Contractor "�f DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW OP. LINE <br /> OTHER 0 <br /> WELL 11WEtL REP-jACErMENT ❑ . " ��,. <br /> ' PUMP INSTALLATION ❑ SYSTEM6REPAIR ❑ `� '* � } <br /> s � DISPOSAL FLO. PR <br /> 1314ANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> AGRICULTURE WELL if OTHER WELL P17SISUMPS , <br /> FOUNDATION -- ' <br /> INTENDED USE TYPE-OF WELL PROBLEM PARE? CONSTRUCTION SPECIFICATIONS Dia of Well Casing �§ <br /> d Industrial fl Open Bott .-Ci ManteEa- -Dia. of Well Excavation <br /> ' Type of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy depth of Grout Sea{ Type of Grout - <br /> Public F-1OtherCl Delta , <br /> —."Appro�. Depth I i I Eastern S_uriace 5e3 I�stallad by <br /> I I I rr i9apon r f 1 State Work bone <br /> Repair Wotk.Done ❑ Type of Pump H.P. <br /> f Well Destruct'O El Well Diameter Sealing Material (top 50'1 <br /> r <br /> Depth Filler Material {Below <br /> TYPE OF SEPTIC WORK:.. NEW INSTALLATION Ml REPAIR/AIaDITION I 1 DESTRUCTION C710N l 1 alvailableseptic <br /> w thin 200'feestem tt)ed if public 4 w Jr is <br /> Installation will serve: Residence.=__Commercial� Other <br /> I <br /> Number of living units: Number of drooms4+ 5 f t Water table depths <br /> Character of soil to a depth of 3 feet: l No. Compact <br /> SEPTIC TANK / Type/Mfg Capacity 1." t F r <br /> l } r Method of�DlspcPal ` yam"" <br /> PKG. TREATMENT PLT. ❑ h ti ' .5 a •- k <br /> (��/ Eoltndati � ' 'pr�oyerty, u'�' <br /> Distance to nearest: Well�. <br /> I <br /> . t <br /> D ash. <br /> Total lengtfilsiie`-- <br /> 1 LEACHING LINE ❑ No. & Length ofilines _ pro ert Liners <br /> Foundation P y -� <br /> FILTER BED ❑ Distance to nearst: Well J / <br /> SEEPAGE PITS ljI Depth } I <br /> Size �` �Nurjlber _ <br /> SUMPS Ik Distance to nearest: Well l <br /> Foundation� Property Line = ' <br /> DISPOSAL PONDS ❑ ;4 <br /> i hereby certify that 1 have prepared this application and that the work will be done irl accordance tiyith San~Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Lbcal Health Di'strict.l y <br /> Home owner or licensed agent's signature certifies the following: "1certify that in the performance of the work for which this permit is issued, k shall not <br /> 1employ any person in such manner as to become'subject to workman s compensa[ioriZ�aws of California Contractor's hiring or sub contracting signature <br /> certifies the following: certify tha in the performance of the work for which this pier mit is issued, I shall employ persons sihject to workman's omp8nsa__ <br /> Alaws of Ca' nia " 1_- ) <br /> � . <br /> x -The <br /> 'pe <br /> u t ca or all r wired ` ctio s. Complete drawing on r rse sde� <br /> 1 ti: s c �, v�•% Date: <br /> - I E Title: <br /> Signed `• <br /> �.,•�r-^ �I � e <br /> F DERARTMENT 115E 0I�LY %1y 1 , <br /> i <br /> e w�,� Area <br /> Applicati l Accepted by '\ ` rI <br /> w K r Final lns�iection 6y Date <br /> 'Pigor Grout Inspection by jDate <br /> k F 1 <br /> Additional Comments:_ -- - i <br /> 5tk 466''8781_ ❑ Lodi 369-3621 'C7 Manteca 823-7104 ❑ Tracy 835=6365 '�� <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax Stk., CA 95201 <br /> r ] <br /> CASH DATE PERMIT NO. <br /> IFEE AMOUNT DUE AMOUNT REMITTED <br /> NFO <br /> CK RECEIVED BY <br /> tt 3 <br /> +.EH 13.24 IREV.1 i H 51 <br /> EH 14-28 <br />