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i APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL°HEALTH DISTRICT <br /> 1601 E. HAZEL I ON'AVE:, -STOCKTON, CA <br /> Telephone {208) 466-6781 <br /> _ PERMIT EXPIRES IRYEAR'FROW-DATE ISSUED abr;cl <br /> L, YfComplete In Triplicate) ` ""a F`C <br /> Appitcation is hereby made to the San Joaquin Local Health District for'a f made H compliance with San Joaquin County Ordinance No.549 for sewage or No. 1 for ell/pump and the Rules and Regulations of the San Joaquin <br /> P' <br /> to construct and/or install the work herein described. This application is <br /> ` <br /> Local Health District. t"y y 982` e <br /> Job Address XIA :r, f i. 1 t �? c- i?�". <br /> F i '1r f City! Lot' <br /> Sae pM'' <br />• Y�I /%/ /y�(/ Z.. F11E, L515 Rr` .Ei.,- 's :'.� > <br /> — Owner's Name =.` <br /> Address - <br /> .. ==Phone <br /> Contractor �� Address � 1111 <br /> G�/ �� �_ � � -•C:�7-a 5 7 r <br /> TYPE OF WEL /P P: NEW WELL ❑ License No. re �. <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br />' <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ 11 1��~ x <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ 7 -iQ3 t <br /> SEWER LiNES DISPOSAL FLD. <br /> FOUNDATION PROP. LINE .. <br /> AGRICULTURE WELL OTHER WELL PiTS/SUMPS <br /> INTENDED USETYPE OF WELL .PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial Y ❑ Open Bottom ❑ Manteca f ' + <br /> 11 Domestic/Private acDia. of Well Excavation _ Dia. of Well Casing <br /> ❑ Gravel Pk Tracy Type of CasingI q* $ <br /> Public ❑ Other - ❑ Delta Specifications i <br /> E3 Irrigation Depth of Grout Seal <br /> --Approx. Depth ❑ Eastern -Type of Grout <br /> Repair Work Done, ❑ T 1, `�$y�fac Seaf Installed by t <br /> Type of Pump H.P. /arlJ - --. <br /> Well Destruction ❑ Well Diameter State Work Done - r <br /> Sealing Material (top 50'I <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIWADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve. Residence! Commercial <br /> Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: t �l <br /> SEPTIC TANK ❑ Type/Mfg I Water table depth <br /> � - w <br /> PKG. TREATMENT PLT. Q CapacityNo. Compartments <br /> + <br /> 'Method of Disposal \ <br /> Distance to nearest: Weil <br /> E Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of fines -r 1 <br /> FILTER BED ❑ Distance to nearest: Well Total fengthlsize I <br /> _ Foundation_ Property Line <br /> r <br /> SEEPAGE PITS ❑ °Depth -�• - <br /> Size Number { / <br /> SUMPS ❑ Distance to nearest: Well / <br /> DISPOSAL PONDS ❑ Foundation Property Line <br /> I hereby certify that i have prepared this appnee with San Joaquin county ordinances <br /> lication and that the work will be done in accorda ; state laws and llI <br /> rules and,regulations of the San Joaquin Local Health District. J <br /> Home oner or licensed agent's signature certifies the following:."I certify that in the'perforrhanoe 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."Contractors 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' tion laws of Calffornia."� p <br /> � P Y personss I ubioct to workman's compensa- <br /> The applican u call for r uire insppec ' ns. Complete drawing on reyame ' <br /> Signed { +v <br /> Title <br /> Date: r <br /> 41 <br /> FOR DEPARTMENT USE ONLY r k <br /> Application Accepted bya` <br /> (( Date'��` Area <br /> Pit or Grout Inspection by ' <br /> Date - l Inspection bV <br /> a Date.r <br /> Additional Comments: <br /> ❑ Stk 466-67g} Ll Lodi 369-3621 ,. ,_ _ ... --- >• -a - _ - - <br /> ❑ Manteca 823-7104 ❑ Tracy 835-63135 ! <br /> `Applicant- Return ail copies to: Environ ent I Health PermiilServices 1601 E. Hazelton Ave., P,o. Box 2009, Stk., CA 95201 <br /> FEE F z r <br /> MOUNT DUE <br /> INFO ,AMOUNT REMITTED H RECEIVED BY DATE' - <br /> PERMIT'N0. <br /> +EH1&24(AEV,t/.e5) �� - 57611" T <br />