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- /o <br /> APPLICATION.,FOR,PERMIT �^ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL—ION AVE., STOCKTON, CA <br /> Telephone (209) 466-51'81 . -,�• <br /> :� T R( abiaoB 10 090140 !:`' c.c <br /> PERMIT EXPIRESA YEAR ER•OM DATE 1SSUED 10 <br /> 6 •.- „ �, .- •e: �^�.:.�.� .i�.«�l�{Complete in,,Tl'iplicate}le=.:.r�<<:.}c. A'I.�i#�>{x��°'-i,:�:��.�3;.±����r.=.,�> �.•i."' ,.. <br /> , <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+maith etSSan-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./ 1#f'"!11-0.El 11, <br /> /Jr�y I �/C 4�U 1Ct ✓#tea,,,4 7[# al'{i �. f {s �J7 <br /> AI­ <br /> City �:` Lot Size <br /> Job Address . . <br /> _dress Phone <br /> Owner's Name = # <br /> �'6 .rY� License No. zr Phone.oG —911d <br /> Cont actor's Name <br /> TYPE OF WELLIPUMP: . NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I <br /> PUMP WSTALLATION. ❑ —SYSTEM,REPAIR D OTHER ❑` <br /> DISTANCE.TO,NEAREST:._.SEPTIC TANK, <br /> i SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i 1 <br /> INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> -❑ Industrial ,.i-- ❑ Open Bottom _ ❑ Manteca Dia. of Well Excavation <br /> T of Casin Specifications <br /> ❑ Domestic/Private ` ❑ Gravel Packyf <br /> L3 Tracy Type g t Type of Grout <br /> Y ..'.❑ Public ❑ Other ❑ Delta Depth of,,GroutSeal r <br /> ❑ Irrigation -; Approx.'Dep4h..—.;C�-Eastern__J Surface Seal Installed by <br /> H.P. <br /> I State Work Done <br /> Repair Work Done. ❑ Type of Pumpw ° <br /> Well destruction } ❑ i Wel1rDiameter Sealing Material (top 50'! I <br /> _ -Depth Filler Material (Below 50'} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION.❑ REPAIR/ADDITION DESTRUCTION ❑ aNailabpelwith5ne200 feet.) <br /> if public sewer is <br /> _ f Z <br /> Installation will serve: Residence— Commercial✓, Other <br /> Number of living unifs:, Numb of bedroomsIL f <br /> Water table depth (26 <br /> Character of soil to=a depth of 3 feet:#f- t <br /> No. Compartments <br /> SEPTIC TANK, 'ElType/Mfgf __ j Capacity Method of Disposal t <br /> PKG. TREATMENT PLT.'❑ 1� € i <br /> I �.`.. Fun Property Line <br /> Distance to nearest:; Well Foundation � f <br /> k � � <br /> LEACHING'LINE No. &Length of lines _ IF <br /> To Lal length/size �R <br /> FILTER BED ❑ 'Distance to nearest:; Well. s Foundation ;f 2_0 Property Line F <br /> SEEPAGE PITS Depth I Z. Size. � Number <br /> `SUMPS [- Distance to near st: ` 1NeI 4Foundation <br /> Property Line S6 t <br /> DISPOSAL_PONDS. ❑ 1 <br /> ' I hereby certify that,l have prepared this application and that the work will be done in accordance with Sart 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- which this permit is issued, I shall not <br /> the performance of the work for <br /> employ any person in such manner as to'become subject to workman's compensation laws of California."Contractors hiring or sub contracting signature <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 /> tion laws of California." <br /> The applicant II for all required irtspe tions. Co plate drawing an raver ide. <br /> -- Date: <br /> et <br /> Signed Title:• i. <br /> . <br /> 4 <br /> _ FOR DEPA TMENT USE ONLY - <br /> - -.. o k .' <br /> }__ r Date Area <br /> Application Accepted by s <br /> # <br /> Data <br /> Date Final Inspection-by <br /> Pit or Grout Inspection by <br /> Additional Comments: i , <br /> ❑ Stk 466-6781 p Lodi 369-3621 _ ❑ Manteca 823 7104 C� 7racy�8r63B5 <br /> Applicant Return all copies to: Environmental Health Permit/.Services 1 EHazelton Ave., P.O. Box 2009, Stk., CA 95201 3 <br /> CK DATE PERMIT"NO. <br /> :a + <br /> n1N <br /> gMOUNTDUET` AMOUNT REMITTED CASH RECEIVED BY+EH 13241REV.161631 , <br /> EH 14-28^ <br />