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; <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 <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 <br /> Local Health District. <br /> Job Address L /�V tJ,(�L7 �C� City Lot Size— 6CAFS_ pM <br /> Owner s Name . ... _ Address one <br /> Contractor's Name' <br /> IP61C �L? a License No. Phone <br /> TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ElDISTANCE TO NEAREST;,SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION' "-' '"""" AGRICULTURE'WELX" '`"`- <br /> OTHER WELL PITS/SUMPS <br /> ,INTENDED USE /TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial',,,,, ❑ Open Bottom ❑ Manteca is *'Dia. of,Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy <br /> El Public [D Other El Delta Type of Casing <br /> Specifications <br /> Depth of Grout Seal Type of Grout <br /> ❑ Irrigation <br /> --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done' ❑ Type of Pumps <br /> YP p. H. �� State Work Done <br /> Well Destruction ❑ Well Diameter,,.----------. Sealing Material {top-50'►.. --. $ <br /> Depth Filler Material iBelow 501 a <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION—X DESTRUCTION ❑ iNo-septic system permitted if public sewer is <br /> available within 200 feet.) <br /> .Installation will serve: Residence -Commercial�' Other �r s <br /> .'Number of living units: Number of bedrooms _ / <br /> Character of soil to a depth of 3 feet: <br /> Water table depth _ ,� <br /> SEPTIC TANK ❑ Type/Mfg .. Capa_c_ity No, Compartments <br /> PKG. TREATMENT PLT. 171 �{f �`n y y,, %,Y f1 Method of Disposal <br /> Distance to nearest:` Well Foundation ,+, '%T Property Line t <br /> LEACHING LINE No. & Length of lines :+7 <br /> FILTER-BED ` _ = Total length/size <br /> } 1J 4 k ,❑ i Distance to nearest: 3 Well . I <br /> --� Founaa,ion ' Property Line <br /> SEEPAGE PITSDepth Number <br /> SUMPS ' Distance to'n-­'est: Well�� Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> w <br /> hereby certify that f have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and f <br /> rules and reguia_tions of the San-:Joaquin Local Health District. I <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 f <br /> employ any person in such manner as to became subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies tile-following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of Cafiforni <br /> The applicant mus all r all re i=ions. Complete drawing on reverse side. <br /> Signed - Title: Date: <br /> W,� # FOR DEPARTMENT USE,ONLY <br /> Application Accepted by mokauJ Date —�7—� \ Area d <br /> Date <br /> Final Inspection by. <br /> `Q <br /> Pit or Grout Inspection by —6�4 Data <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369;3621 -C] Manteca 823-7104 l ❑ Tracy 835-6385 ; <br /> Applicant- Return all copies to: Erivironmental Health Permit/Services 1601 E. Hazelton Ave.,, P.O. Box 2009, Stk., CA 95201FEE <br /> { <br /> INFO AMOUNT DUE EAMOUNT REMITTED CK.# r� l <br /> RECEIVED BY DATE PERMIT'NO. <br /> CASH�— yj / <br /> + EH 1428 IRI:V.10!831 S� " /� 4 <br />