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APPLICATION FOR PERMIT <br /> CA.i — <br /> SAN JOAO.UldLOii ." L�HEALTH DISTRICT <br /> . _kk <br /> 1601 E. HAk"'T 0WAVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR-FROM DATE ISSUED'' <br /> V <br /> (Complete in Triplicate) <br /> construct and/or install the work herein described. This application is <br /> Health District for a permit to <br /> Application is hereby made to the San Joaquin Local <br /> made in compliance with San Joaquin Cddnty Ordinance No.549 for sewage or No. 1862 for well/pump and the,Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Lot- PM <br /> �_Ax�e <br /> Job Address 3 AM4A) City <br /> Address- -Phone <br /> Owner's Name LO j D <br /> -7q(, <br /> /12L±?j L License N Phone <br /> Contractor <br /> Address je IL <br /> TYPE OF WELL/PUMP: — ;J NEW I WELL D WELL REPLACEMENT 0 DESTRUCTION U <br /> IR 0 OTHER C <br /> SYSTEM REPAIR PUMP INSTALLATION 0 <br /> DISPOSAL FLD._ PROP. L <br /> DISTANCE TO NEAREST: SEPTI�`TANK SEWER LINES- INE <br /> — <br /> FOUNDATION TT AGRICULTURE�WELL _ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF" ELL PROBLEM AREA 1-CONSTRUCTION SPECIFICATIONS <br /> Dia- of Well Casing <br /> 171 Manteca,, Dia. of Well Excavation <br /> 0 industrial 0 Open Bottom <br /> I:] Domestic/Private ID Gravel Pack D ,Tracy Type of Casing Specifications <br /> Type of Grout <br /> 0 Public El Other D Delta Depth of Grout Seal <br /> El Irrigation ---Approx. Depth Ll Eastern Surface Seal Installed by <br /> Repair Work Done F] Type of Pump H.P.�T State Work Done <br /> Well Destruction C-1 Well Diameter Sealing Material stop 50') <br /> Depth Filler Material (Below 501 1 <br /> TYPE OF SEPTI ALLATION D REPAIR/ADDITION LD DESTRUCTION Y(No septic system permitted if public sewer is <br /> C WORK: NEW INS k available within 200 feet-i <br /> Installation will serve: Residence— Commercial— Other <br /> N.umber of living units: — Number of bedrooms !71 <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Capacity— No. Compartments <br /> SEPTIC TANK 0 Type/Mfg <br /> Method of Disposal <br /> PKG. TREATMENT PLT. El I - <br /> Distance to nearest: Well 1`6�nclation— Property Line <br /> t L Total length/siz <br /> _LEACHING LINE 0 No, & Length of lines <br /> !1! Property Line <br /> FILTER BED 0 Distance to nearest: 'Well Foundation <br /> 0 Depth A.. Number <br /> SEEPAGE PITS Size'-' Property Line <br /> J Well Foundation <br /> SUMPS 0 Distance to n�aresi-.'-..- <br /> F DISPOSAL PONDS Ll <br /> k ill be done in accordance with San Joaquin county ordinances, state laws, and <br /> k I hereby certify that I have prepared this ap�pkatiofi_ancl that the wor. w <br /> rules and regulations of the San Joaquin.Local Health District. -1 . <br /> Home owner or licensed agent's signaiu�ri,odrtlfies the following:."I certify that in the performance of the work for which this permit is issued, I shall not <br /> I . 1� - —"compensation laws of California."Contractor's hiring or sub-contracting signature <br /> employ any person in such manner as to become subject to,workman s <br /> certifies the following-"I certify that ihthe performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> -The-applicant-must call 11"!for all nspe tions:nCompleteCopletw drawing on ieverse side.r <br /> I . 1 - <br /> Date: <br /> Signed X itle <br /> FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted-by -7 <br /> Pit or Grout Inspection by Oat, Final Inspection by Date T: <br /> AcMitional Comments-. 0 Manteca 8M-7104 El Tracy 835-6385 <br /> Stk 466-6781 El Lodi 369-3621 <br /> 1601 E. Hazetton Ave., P.O. Box 2DO9, Stk., CA 95201 <br /> f Applicant- Return all copies to: Environmental Health Permit/Services <br /> FOR DEPARTMENT <br /> [ A <br /> �NO <br /> FEE AMOUNT DUE AMOUNT REMITTED. c RECEIVED BY DATE PERMIVNO- <br /> INFO <br /> + EH 1324(REV.1/8 5) <br /> EH 14-26 <br />