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APPLICATION!FOR.PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON.AVE., STOCKTON, CA <br /> Telephone (209i466-6781+ ► <br /> PERMIT EXPIRES,1,YEAR FRO M,DATE ISSUED. <br /> ,„(Complete in Triplicate)_ <br /> I <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 compliancwith-San Joaquin County:Ordinance No.549 for sewage or No. 1B62forwell/pump:and the Rules and Regulations of the San Joaquin <br /> Local Health District.-tr .7 ,z' �; tg lr<3'1 t; t <br /> Lot Size t PMS <br /> Joh Address �" sY City --•.— <br /> f _ ,�L� *. <br /> �. �i74r �� Phone U <br /> Owner's Name <br /> td R,IL Address <br /> t _ �[iTi74{' Atk,hQ ui cense No.. AEPEMENT <br /> Phone <br /> Contractor's Name <br /> TYPE OF WELLIPUMP:' NEW. ❑ WELL ❑ DESTRUC ION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> _ PUMP INSTALL'AT(6f Y <br /> t4 SEWER LINES _��- DISPOSAL FLO. PROP.,LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> PkTS/SUS S <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED_USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> ,❑ Industrial r ❑ Open Bottom Q Manteca Dia. of Well Excavation— Specifidatio <br /> ❑ Tracy Type of Casing <br /> Domestic/Private ❑ Gravel Pack .,1 1 "" Typ�of Grout <br /> Public <br /> ❑°Other Q Delta Depth of Grout Seat # �r. , <br /> ---Approx. Depth ❑ Eastern Surface Seal installed by <br /> ❑ Irrigation ; ,f State Work Done <br /> .Repair Work Done ❑ Type of'Pump � , H. . 14-_ ,-*f.. -> �,. _ <br /> �+ . <br /> �Seali g M e ial Itop 501 J <br /> Well Destruction ❑ Well Diameter Filler Material-(BeI0w 50'1.-. <br /> r. Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/AD0171ON ❑ 'DES�TIR CTION ❑ 'alvailab system <br /> in 200 feet.) if public sewer is <br /> k <br /> Installation will serve: Residencel.— Commercial—1 Other <br /> Number of living units: Number of bedrooms j Water table depth <br /> Character-of-soil to a depth of 3 feet: —.. Capacity`, No. Compartments <br /> SEPTIC TANK a ❑ Type/Mfg o. <br /> Method of Disposal <br /> `+�+ <br /> r -�`k <br /> �PKG. TREATMENT'PLT:❑ Foundat"ion Property Line C3 <br /> Distance to nearest: Well <br /> r Total length/size <br /> LEACHING UNE i❑ S No. & Length a lines _,/ Foundation Property Line <br /> FILTER BED <br /> Number Distance to nearest: Wali <br /> Sizef Number <br /> SEEPAGE PITS ❑ Depth t , <br /> w Foundation Property Line <br /> -4 j ❑° Distance to nearest: Well <br /> SUMPS",. �,. ,i � <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this applicatio 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 H alth District. <br /> Home owner or licensed agent's signature ceryt,Ties the following: "I certify that in the performance of the work for which this permit is issued, I signature <br /> shall not <br /> employ any pars in such-manner as to be�omo mance of the wo k foto swh ch this tperm t is issuof ed,I shall employ persons rnia."Contractor's 1subject t workmanring or 's sub-contracting <br /> certifies the fol ng."I certify that in therpe _ " <br /> on laws of C lif rnia."t` - t <br /> The applica call for 1 r i�d io s. Co tete drawing�on reverse side. <br /> f` f Title: vi,`—~ El — Date: <br /> 1 Signed A' <br /> FOR DEPARTMENT USE ONLY <br /> Data Area <br /> Application Accepted by <br /> Pit or Grout fns ction by <br /> Date��-- <br /> Final Inspection by Date <br /> t <br /> e Additionaledomments`. <br /> ❑ 5t��Z466 6781 -� ❑ Lodi 369 3621- , ❑ Manteca 823-7104 ❑.Tracy 635 6385 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009r Stk., CA 95201 <br /> j CK <br /> , RECEIVED BY DATE PEfiMIT"N0. <br /> i FEE - 'i AMOUNTFin <br /> EMYTTE. CASH <br /> = 'INFO <br /> '+F%1324(REV.10/831 <br /> EH 14.28 i -. _ - - -�-• <br />