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APPLICATION FOR PERMIT <br /> l' SAN JOAO.UIN'LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br />{ Telephone (249) 466-6781 <br /> PERMIT EXPIRES"1 YEAR,FROM,DATE ISSUED <br /> (Complete in Triplicate).. <br /> . ,-. ;;, °;.:,i: ,.;{.�`Y�a Vii:.:�I..F^- ; r... '!, :_ •.y✓''E.a 4 FL.c a dC it <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or mstail the work herein described.This application is <br /> Joaquin <br /> No.549 for sewage or No..,1862 for well/pump and the Ryles and Regulations of the San <br /> made in compliance with San Joaquin County Ordinance <br /> t <br /> t <br /> Di <br /> Local Health District. p", <br /> r U r T Asp; 1z f C :., shat I is '.•, <br /> L p`�3 Iy� 1 1,5 �AxC°t�GS `1�City Lot Size PM , <br /> Job Address "t t ;`�s. k. ts lr ad ; <br /> k r- phone <br /> ' owner's Name '° 4" i1! _r Address- <br /> j ,?��b 6�-Phone!d' <br /> + CContractor - w Address •Q�. �y License Na. <br /> y i ,TYPE OF WELL/PUMP: NEW TELL.-0,- '. WELL REPLACEMENT❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION Q SYSTEM REPAIRS❑ OTHER ❑ <br /> 4 <br /> 1DISTANCE TO NEAREST: SEPTIC TANK SEWER CINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> s❑ Industrial L] Open Bottom, ,..❑_Manteca �,_ Dia. of_WeU Excavation Dia. of Well Casing <br /> r Specifications <br /> }❑ Domestic/Private Q Gravel Pack ❑ Tracy Type of Casing <br /> 1p Public '❑ Other + LlDelta Depth of Grout Seal - Type of Grout <br /> '❑ Irrigation ,: ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> .Repair Work Done d Type of Pump H.P. State Work Done \ f <br /> p'. ' �, Sealing Material (to 50'1 l� <br /> Well Destruction= ❑t Well`Diameter 9 P ; F <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIR/ADDITION❑ DESTRUCTION ❑ (Na septic system permitted if public sewer is <br /> available within 200 feet.) fl. <br /> ' ¢ <br /> r Installation will serve: Residence✓ Commercial—, Other u.. s <br /> Number of living units: -)-- Number of bedrooms t <br /> Water table depth <br /> Character of soil to a depth of 3 feet: , z <br /> 1 I Capacity No. Compartments <br /> �. SEPTIC TANK iii Type/Mfg ' <br /> I r- Method of Disposal <br /> PKG. TREATMENT PLT, ❑ 7 �--�-� <br /> Distance to nearest: Well 1 Foundation,"moi Property <br /> /�fJ Line <br /> •.. i <br /> 'r LEACHING LINE No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well 4� 2.►.!� F ndation�- Property Line <br /> �;, � ,ate 'r ' �.�. -•- _. <br /> SEEPAGE PITS ❑ Depth Size <br /> A t fi Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with SaWJoaquin*county ordinances; state laws, and <br /> Mules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature!certifies the foil-a-wing:"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 tolworkiihan's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: u certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California."' `°� i <br /> The applicant must tail for II requi i inspections. Compl�te drawing on reverse side. <br /> ! Date: <br /> Signed <br /> FOR DEPARTMENT USE ONLYr <br /> Area <br /> Application Accepted,by Date <br /> 1 _ �•.9 <br /> Pit or Grout lnspection by-� ! "" t Date Finallnspectiori by pate <br /> Additional Comments: <br /> O Stk 466-6781 ❑ Lodi 369-36214 ❑ Manteca 623-7104 ❑ Tracy 835 6385 <br /> l Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r <br /> - - ~- , - <br /> -CK# _ RECEIVED.BY, <br /> "FEE } <br /> INFO ~AMOUNT DUE:,- AMOUNT REMITTED CASH DATEPERMIT`NO: <br /> +•EH 13-24-(REV,­r/s5)- ..D C7 � 171 <br /> b— <br /> f EH 14-28 <br />