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i <br /> APPLICATION FOR PERMIT <br /> $ SAN JOAO,UIN.LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,-STOCKTON, CA <br /> 'Telephone 12091 466-6781 . <br /> PERMIT EXPIRES 1 YEARTROM DATE ISSUED w <br /> (Complete in:Triplicate) <br /> Application is hereby made to the San Doran ui 0 ordinance No.District Local Health 49 for sewage or cation is <br /> INo 1862 for well//pump and the Runes and t to construct and/or install the work herein <br /> R gulations of he Sanl Joaquin <br /> made in compliance with San Joaquin county LW C.Z.Ix . + <br /> Local Health District." fj1 v <br /> e}1 tel' ' Ql�4� �' Cit„ �/` �-Lot Size PM t <br /> Job Address �Q '/„ <br /> r pyla J �ddress- ID .77� IQCF�r /�U Phone <br /> Owner's Name <br /> Address License No. <br /> Phone <br /> Contractor DESTRUCTION ❑ <br /> NEW ELL WELL REPLACEMENT ❑ <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR d OTHER O <br /> PUMP INS 7A <br /> J EWER LINES _ZDr DISPOSAL FLD. PfIop. L1NE <br /> DISTANCE TO NEAREST: SEPTIC TAN RICULTUR ELL OTHER WELL PITS/SUMPS <br /> FOUNDATIO <br /> NTENDED USE TYPE OF WELL PROBLEM EA ONSTRUCT101V SPECIFICATIONS -• Dia'of WeIL:Casin <br /> Dia. of-Well Excavation , <br /> ❑ dust ial�.,,,,.�,,,,. , E_Open Bottom,E Manteca a ...� Specifications <br /> It Domestic/Private El Gravel Pack ❑ Tracy Neppth'of <br /> e of Casing <br /> ❑ Other j pelt Grout Seal <br /> Type of Grout <br /> blic el tom- rface-$eal Installed by <br /> El Irrigation �ppr6x Depth ❑ E tern _ <br /> H P _ / State Work.Done <br /> Repair Work Done i Type of Pump -mer Sealing Matenalit p 50 1 v w <br /> Well Diameter ti - <br /> Well Destruction ❑ ,.sem 'low•501 <br /> Depth "' .��iller-Material'iSe <br /> available within 200 feet"} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPA'!R/ADDITION:�.��ESTRUCTION C7 (No septic system permitted if public sewer is <br /> Installation will serve: fiesidence `•Commercial � ;Other�— <br /> Number of living units: Number of bedroms y CL.. �! �CVaTer table depth <br /> Character of soil to a depth of 3 feet: ,i`� � a-- ��—Q-- No. Compartments <br /> SEPTIC TANK Type/Mfg Method of Dispos ' <br /> ;f j i~ �` al <br /> PKC. TRATMENT PLT. ❑ Property Line__,S <br /> Well� — Foundation—�f - — , <br /> r Distance to nearest -? �''�` _ <br /> f 7 � r t <br /> -- , <br /> �. � T tai length/size <br /> No" & Length of lines ' -� fi? <br /> LEACHING LINE Q� Foundation Property Line <br /> FILTER BED .❑ Distance toanearest: ; Well — <br /> _ <br /> t'Size Number <br /> SEEPAGE PITS ,T ❑ Depth Property Line R, <br /> , SUMPS .0 . Distance to nearest: �I? <br /> WeU Foundation � .. <br /> ! ,z� `;' <br /> DISPOSAL PONDS Q <br /> d. <br /> I <br /> l hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> not <br /> rules and regulations of'the San Joaquin Local Health District.g work for <br /> this permit is issued, <br /> Home owner or lice fed agent's annergas to become subject workman'srtcompensat on lify that in the aws soof California-"Contractor slhir ng c subs cont act s c signatureesa- <br /> employ any person In such <br /> certifies.the 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 /> j I <br /> tion{aws of.California.' _ ...a .r-.- •+- ;�> <br /> The epplic ust c for all required inspections" Complete drawing on reverse s�dN <br /> ` ... ( Title: W Date: <br /> , <br /> Signe j <br /> FO DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by { Date <br /> l r Date Final Inspection by „- <br /> Pit or Grout Inspection by <br /> Additional Comments: Tracy 635-6385 <br /> L7 Stk 466-Ml ❑ Lodi 369 3621 ❑ Manteca 623 7104 <br /> : Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> K RECEIVED BY:, DATE PERMIT'NO. <br /> FEE MOUNT(DUE AMOUNT REMITTED CA <br /> INFO = b <br /> + EH 13-24{REV.i <br /> EH 1428 LLL _ <br />