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f <br /> APPLICATION,FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (20J) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <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 Rules and Regulations of the San Joaquin s <br /> Local Health District. <br /> Job Address r <br /> " Dr. City TrCY Lot Size arcs PM <br /> Owner's Nam 1", Address --P 0 Box 327 _ Phone 8358 293a r <br /> Contractor's Namer' ` <br /> License No. X69:921 Phone 835�2�0`Z <br /> TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT a DESTRUCTION <br /> Well by T1e)ti*%ri gWIN$tWTALLATION M SYSTEM'REPAIR ❑ OTHER ❑ 5' <br /> DISTANCE TO NEAREST: SEPTIC TANK 7:p.CL SEWER LINES _100 DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL- OTHER WELL PITS/SUMPS <br /> MibaDIME TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing J <br /> L7 Domestic/Private f Gravel Packg Tracy Type of Casing Ste Specifications <br /> ❑ Public''­ ` ❑ Other ❑ Delta Depth of Grout Seal Type of Grout Vl <br /> ❑ rri ation <br /> 9 t ---Approx. Depth E3 Eastern Surface Seal Installed by- <br /> Re air Work Done ❑ T '' <br /> P Type of Pump H.P. State Work Done <br /> Well Destruction Well Diameters _ Sealing Material (top 50') <br /> Depth Filler Material (Below 50') Frawl <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system per if public sewer is {� <br /> �I - available within 200 feet.) v' <br /> Installation will serve: Residence.,_ Commercial_ Other <br /> Number of living units: Number of bedrooms Y <br /> Character of soil to-a depth of 3 feet: 1 '• .Water table depth <br /> SEPTIC TANK ❑ Type/Mfg .I Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation.r Property Eine <br /> .I � 1 <br /> LEACHING LINE ❑ No. & Length'of lines Total length/size <br /> FILTER BED D Distance to nearest: Well Foundation Property Line / { <br /> SEEPAGE PITS ❑ Depth Size Number t <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I <br /> I hereby certify that I have prepared this appllcation and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's 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 person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,.)shall employ persons subject to workman's compensa- <br /> tion laws of California." I �.,:€• <br /> The applicant call for all;re fired ctio . C e drawing on reverse sidd. <br /> Signed itle: I"iOLt1tr,toY' Date: 7-24­85 <br /> FOR DEPARTMENT USE ONLY. <br /> Application Accepted by Date–716-� Area ©� <br /> Pit or Grout Inspection by Date i Final Inspection by' Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8315-6385 <br /> Applicant- Retur all copies to: Environmental Health Permit/Services"1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO UE OUNT R ITTED CK CASH <br /> INFO RECEIVED BY DATE PERMIT NO. <br /> + EH 13.24 4REV,10/831 <br /> EH 14-28 <br />