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t; <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN'LOCAL HEALTH DISTRICT - l <br /> 1601 E 1fi4ZELTON,AV,E., STOCKTON, CA ���� � �� €, �€ <br /> Telephone (209) 466-6781 t' ' <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i"' r= 198D <br /> (Complete in Triplicate) <br /> �• <br /> t� .A H EA4�TH <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work heWfi b�P4 n is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Remwaot quin <br /> Local Health District. <br /> Job Address 3A 3 LODCity ' of Size PM <br /> i <br /> Owner's Name Address L ris Phone �� <br /> 66 b <br /> Contract"'A +rn Address`�' h3fl� ���� License No. �� Phone <br /> I <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ <br /> DISTANCE= TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL%— PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial 1❑ Open Bottom ` ❑ Manteca. Dia. of Well Excavation Dia. of Well Casing t 1 <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Wf • t <br /> 1-1 Public Cl Other Cl Delta Depth of Grout Seal Type of Grout _ W <br /> I I Irrigation ' _Approx. Depth, ( I tastern Su`�a� Seal,lnstalled by <br /> Repair Work Done Type of Pump H.P. 1 State Work Dane <br /> I <br /> Well Destruction ❑ I Well:Diameter Sealing Material (top 50.1 <br /> Depth ~� Filter Material (Below 501 <br /> TYPE OF SEPTIC WORK:t NEW INSTALLATION I] REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> j available within 200 feet.) <br /> Ihstallation will serve: Residence Commercial;_ Other <br /> Number of living units: j Number of bedrooms. 5 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Q TOW Mfg-- '-- -��""- """"" "°'"� ~✓Capacity" "��EVo. Compartments <br /> PKG. TREATMENT PLT. p I i Method of Disposal <br /> Distance to nearest: Well Foundation Property.Line 7 <br /> LEACHING LINE C71 filo. & Length of lines Total length/size <br /> FILTER BED ❑. Distance to nearest: Well Foundation Property Line <br /> ! I <br /> SEEPAGE PITS l I Diepth Size Number <br /> r <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS I I } <br /> I hereby certify that I havejprepafed this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the Sar, Joaquin Local Health Di%trict. <br /> Home owner or lice E 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 pe n in suchjmann as to become subject to workman's compensation Ia*s of California." Contractor's hiring or sub-contracting signature <br /> certifies the Rowing: ',I ca rtifyt tin the perform ce of o for which this permi . issued, I shall employ persons subject to workman's compensa- <br /> tion laws f Galifornia <br /> The ap icant mu q''I require mplete d ing on revers e. <br /> f ,`��� <br /> Signed Title: Date: '716 ldol�� <br /> lFQR DBPA TMENT USE ONLY �1 <br /> r !`= Area <br /> Application Accepted by Date <br /> Pit or Grout Inspection by Date Final Inspection by Date h2. <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 INFO `AMOUNT DUE AMOUNT REMITTED CK <br /> RECEIVED BY DATE PERMIT-NO. <br /> +.EH 13-24 TREY.i/H s I � r� <br /> EH 14-28 <br />