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Y ` <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 /> G ICornplete 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 /> � <br /> 7 1, <br /> 1, 1 -� �, <br /> lrL�__r rVe City Lot Size PM <br /> Job Address i <br /> Axone <br /> Owner's Name Rfm 1 Address <br /> Y k7 <br /> Phone <br /> License s License No_ <br /> Contractor MO <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT D DESTRUCTION Ll ! <br /> f <br /> PUMP INSTALLATION $ SYSTEM REPAIR D e �O..,T��HE��R Q <br /> ICY) SEWER LINES DISPOSAL FL'D:��b><�PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK _.L—._— +- `—�— �ry���� f <br /> FOUNDATION AGRICULTURE WELL 'OTHER WELLfu�PITS/SUMPS Lyda�f' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing r <br /> ❑ Industrial LJ Open Bottom D Manteca Dia. of Well Excavation <br /> 4 �7 Gravel Pack ❑ Tracy Type of Casing—12 Specifications <br /> CV <br /> Domestic/Private } -_ <br /> f Delta Type of Grout <br /> C"1,Public Ll Other Depth of Grout Seal � <br /> I I Irrigation � —_Approx.'Deptfl III Eastern Surface Seal Installed by -- <br /> Repair Work Done. Type of Pump *�Lt-t�-+�— H.P. F State'Work' Dane <br /> W <br /> Sealing Material Itop 50'1' <br /> Well Destruction El Well Diameter 9 1 <br />! Depth L Filler-Material [Beiow.50'1 — k <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION„DESTRUCTION I I (Noseptic systethin m permitted if public sewer is <br /> availabInstallation will serve: Residence t Commercial -Other. <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3'feet:' <br /> i SEPTIC TANK D Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 13 Method of Disposal ° <br /> Distance to nearest: Wdil Foundation Property Line <br /> LEACHING LINE E] No. & Length of lines Total length/size <br /> FILTER BED ❑ Distanceto nearest: Well Foundation Property Line <br /> N <br /> SEEPAGE PITS l'1 Depth I Size _ umber <br /> 1 SUMPS Ll Distancerto nearest: Well Foundation Property Line <br /> fr <br /> DISPOSAL PONDS El <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,-Istate laws, and r <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 shalt 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 the work for which this permit is issued, l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> {. The applican st call for all required inspections. Complete dr ing on reverse side. . <br /> Signed X <br /> Title: ' Date: <br /> OR DEPARTMENT USE ONLY <br /> Date ?Aq,4— � <br /> Area <br /> y s Application Accepted by <br /> ate-� Final Inspection by �" Date <br /> Pit or Grout Inspection by <br /> .- .�. _ <br /> 4,., <br /> 7_ <br /> Additional Comments: .� -74 - <br /> Eleca Stk 466-6781 ❑ Lodi 369-3621 ' ❑ M nt823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 <br /> f <br /> k ' <br /> FEE CK RECEIVED BY DATE PERMIT NQ. <br /> INFO AMOUNT DUE AMOUNT REMITTED <br /> '��19 23c,J r <br /> + EH 13-24 iAEV.rifts) <br /> EH 14-2e - <br />