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APPLICATION FOR PERMIT <br /> SAN JOAQUIN 'LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Teleph6ine (209) 466-6781 <br /> PERMIT EXPIRES 1,YEAR FROM DATE ISSUED"1 7�t- '" <br /> (CohilJlete 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 Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> rr. V f%. MAW <br /> City ".'-1Lot',$jze1 PM' <br /> Job Address llc�Z3 M ZbMF V IC�7 6 <br /> i'D 1., 134 .!.�: - , <br /> Owner's Name AM MAE &/�4 Address Phone ?a <br /> Contract., <br /> _X3t2License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT D DESTRUCTION I!] <br /> PUMP INSTALLATION OTHER 11 <br /> DISTANCE TO NEAREST: SEPTIC TANK — SEWER LINES DISPOSAL FLD.— PROP. LINE <br /> FOUNDATION-�--AGRICULTURE-WELL-::L- """`'OTHER-WELL--777— PITS7SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El lnclustriai4, = 0 Opel Bottom`­ "[D Manteca Dia of Well Excav6tion' Dia. of Well Casing <br /> 'Q Domestic/Private 71 Gravel Pack El Tracy Type of Casing Specifications <br /> --Public Ll Other ED Delta Depth-of Grout Seal Type of Grout <br /> El Irrigation ---Approx. Depth El Eastern Surface Seal Installed by <br /> Repair Work Done El Type of.Pump C;j08 H.P. State Work Done jqVA!P_ <br /> Well Destruction El Well Diameter Seating Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ID REPAIR/ADDITION 0 DESTRUCTION El (No septicsystem permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve:I Residence— Commercial Other <br /> Number of living units:— 'Number of bedrooms iC <br /> Character of soil to a'd,pff;�f 3'feet: Water table depth <br /> SEPTIC TANK 0 'Typi/Mfg Capacity— No. Compartments <br /> PKG. TREATMENT PLT. ED Method of Disposal <br /> <-Lance to nearest: Well Foundation— Property Line <br /> LEACHING LINE ❑ -No. & Length of_lines--rv,,, Total length/siz <br /> FILTER BED El Distance to nearest:. Well Foundation— Property Line <br /> SEEPAGE PITS El/Depih Size Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Ejf� <br /> I hereby certify that I have prepared this application and that the work will be done i ni`accordance with San Joaquin county ordinances, state laws, anc <br /> rules and regulations of'the San Joaquin Local Health District. _e I I <br /> Home owner or licensed',agent's signature certifies the following: "I certify that in the perWrmance 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 /> e <br /> certifies the-following:"I certify that-in-.the-performance-of the work for-which this permit is'iss0ed,'l shall employ peFs6ris subject to workman's compensa- <br /> tion laws of California."I <br /> The applicant fo all r nspections. Complete drawing on reverse�Oe. <br /> Signet Title: Date: <br /> R DEPARTMENT SE ONLY <br /> r-2-0 <br /> Application Accepted bl Date Area <br /> Pit or Grout Inspection by Date finalInspection by en�Date <br /> Additional Comments: <br /> El Stk 466-6781 'Ll Lodi 369-3621 0 Manteca 823-7104 0 Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1061 E.,Hazelton Ave., P.O. Box 2009,4.Stk., CA 95201 <br /> FEE <br /> INFO CASH AMOUNT DUE AMOUNT REMITTED CKRECEIVEDBY, DATE PERMIT'NO- <br /> * <br /> + EH i3-24 4REV.I/B 5) <br /> EH 14-26 —9 q 7 <br />