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I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR"FROM DATE ISSUED {= b <br /> IJ (Complete in Triplicate) <br /> lj t <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 application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joa u' <br /> Local Health District. <br /> r✓S V x! City a Lot Size Q,l�',U- PM r <br /> Job Address 4 I , t <br /> i• I <br /> /L4 <br /> ss Phone 3g <br /> Owner's Name 1Y Address j <br /> Contractor - -� <br /> _�Address_,�7S �� �� '� " License No. <br /> Phone <br /> TYPE OF WELL/PUMP: W WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ - SYSTEM REPAIR_El t OTHER ❑ _ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 7-- ?` DISPOSAL FLD. PROP. LINE <br /> -• F----^- �" "FOUNDATION"" "" AGRICULTURE WELL "+ OTHER'WEL-L PITS/SUMPS — <br /> INTENDED USE TYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICATIONS <br /> 1 <br /> Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Industrial ❑ Open 7 <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other EJ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation �pProx. Depth E3 Eastern Surface Seal Installed by <br />�4 <br /> Repair Work Dane EI Type of Pump H.P. State Work Dane <br /> r <br /> Well Destruction ❑ Well Diameter Sealing Material{top 501 <br /> Depth Filler Material iBelow 50') ` ' J <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION M'•'REPAIR/ADDITION ElDESTRUCTION CI'iNo septic system permitted if public sewer is <br /> available within 200 feet.) �, d <br /> Installation will serve. Resid nce i 'Gomm ficial Other ' <br /> Number of living units:- Number of bedrooms- <br /> Character of soil to a depth of 3 feet: i - Water table depth �'[] <br /> SEPTIC TANK E3. Type/Mfgy n, Capacity No. Compartments �" 0 _ <br /> Method of Disposal <br /> PKG. TREATMENT PLT. C1i t. t j Y <br /> Y Distance to nearest: Well Foundation__L0 Property Line <br /> F. LEACHING LINEQ No. & Length of liries d� Totaf'lengtW1size <br /> /c h . <br /> 1. <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth =Ak,tax fp Size bb Number <br /> SUMPS .21' Distancelio in2arest: ; Well! Foundation -_ property Line { <br /> DISI A PONDS 9 ❑ � % I J^ a <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, arld <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: '9 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;b e subject to,wdrkman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> j certifies the following: '9 certify that in a perfo mance of the iWrk for which this permit is,issued,I shall employ person's subject to workman's compensa <br /> Il tion laws of Califor <br /> The applicant st 11 fo k eq ed in ns. Campaiete.drawing o verse side. �� <br /> Signe __ " �r Date: �— 1 <br /> d �•�' � Title �• <br /> FOR DEPARTMI T USE ONLY <br /> Application Accepted by Date -Area �] �Q <br /> Pit or Grout Inspection by r Date- Final Inspection by3� Date7:: 1Z <br /> Additional Comments: <br /> LDStk. 466-6761- ❑ Lodi 369-3621 E3 Manteca 823-7104 ❑ Tracy '635-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE I AMOUNT DUC AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"N0. <br /> INFO �J` <br /> + EH 13-24(REV.s/65) �` '�3 4 • "I V{'v 6 <br /> EH 14-26 <br />