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+ APPLICATION FOR PERMIT <br /> -^ w „tea!s: <br /> SAN JOAQUIN,_LOCAL"HEALTH-DISTRICT TT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> '-` .PERMIT EXPIRES 1 YEAR FROM DATE•ISSUED-" <br /> (Complete in Triplicate) r <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 d <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. s a <br /> Job Address City � Lot Size PM <br /> � l' I� J. ` <br /> ,�qq <br /> Owner's Name CJS'G�'4'/�- �` 'ST `^ P;�dress -Phone �0 3� <br /> Gontractor ` ft �"I :F�.# Address �. -License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ '` WELL REPLACEMENT-❑' Z� DESTRUCTION ❑ <br /> i ' <br /> PUMP_INSTALLATION.-❑—. .;,SYSTEM-REPAIR-0 -aOTHER-13-�^�""" --.- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER-L'INES DISPOSAL FLD. PROP. LINE ° <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �n`! <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy t Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth ofrGrout'Seal ' Type of Grout F <br /> ❑ Irrigation -214-Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done El Type Yof Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth_ E F r Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTAL T�kn REPAIR'/ADDITION ❑ ' DESTRUCTION ❑ (No septic system permitted if public sewer is ' <br /> p e "`available within 200 feet.) <br /> y� <br /> Installation will serve: Residr en , <br /> R I Commercial' Oth e � � y^ <br /> Number of living units: Number of bedrooms . Az <br /> Character of soil to a depth of 3 feet:':1 4`",. i Water table depth <br /> SEPTIC TANK Type/Mfg Ca ac(ty 1 <br /> No. Compartments <br /> PKG. TREATMENT PLT. *" I �"w <br /> `"^�" - °t Method of Dispgsal <br /> ee <br /> Distance toJJ nearest:=, Well lPJd,. Foundation �� Property Line � _67� <br /> LEACHING LINE �"No. & Length of lines* a s o- ^`''+ T9tal Is I <br /> FILTER BED r_1Distance to'nearest: -Well Zg2 3- 7— Foundation Property Line '- <br /> SEEPAGE PITS ❑ Depth L Size^a ��_-'-' Number <br /> SUMPS 12Distance to nearest: Well+=L Ftioundation Property Line ,.✓' <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that i have prepared this`application and-thet the work will he 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 they work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicantt ca or all required ' spections. Complete drawing on reverse side. <br /> Signed Title Date:/ a i <br /> FOR DEPARTMENT USE ONLY <br /> 74 Application Accepted by Date ��/ Area 07ti - ! <br /> -- <br /> Pit or Grout Inspection by ­� _ Da Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 3 ❑ Manteca 823-7104 -Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental.Health Permit/Services 1601/t. Mzelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> t <br /> FEE AMOUNT DUE ' ., AMOUNT REMITTED CASH RECEIVED BY_ DATE PERMIT"NO.. <br /> INFO <br /> li 00 _7t) ca o 1� (]��! _ �y <br /> I + EH 1324(REV.4/esl _ �a �� y /'! �'f) U((fC�i <br /> EH 14-28 <br /> 1 <br />