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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6781 <br /> PERMIT EXPIRES (YEAR FROM DATE ISSUED <br /> JComplete 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 Illand the Rules and Regulations of the San Joaquin <br /> Local Health District. I y� <br /> S' e3 "n City Lot Size <�J X } ` PM <br /> Job Address <br /> ��d'3 � 9 Phone J <br /> Owner's Name Address <br /> `) Z�} �O-6h, r 6(4 License No.�7�� _-Phone 3��"��33 <br /> Contractor <br /> f� t Address <br /> NEWTWE - - <br /> LLD - .WELL.REP-LACEMENT,❑ �,r_DESTRUCTION LJTYPE OF WELLIPUMP: *� <br /> PUMP INSTALLATION ElSYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLO. PROP. LINE <br /> i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> INTENDED <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ industrial ❑ Open.Bottom ❑ Manteca Dia. of Well Excavation <br /> rt y Specifications <br /> ❑ DomesticIPrivate ❑ Gravel Pack ❑ Tracy Type of Casing <br /> C i Delta Depth of Grout Seal Type of Grout — <br /> M Public f] Other # _ <br /> I Irrigation —.Approx. Depth t I Eastern Surface Seal Installed by <br /> . r. <br /> Repair Work Done ❑ T 'H—p:'� State Work Done_ <br /> ype of Pump y <br /> Well Destruction ❑ Well Diameter Sealing Material atop 50') N <br /> Depth 1 Filler Material IBelow 501 ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION DESTRUCTION I I (No septicilable system <br /> m rmiitued if public sewer is <br /> I <br /> f Installation will serve:" Residence Commercial Other <br /> Number of living units: — Number oo � 901 <br /> (� Water table depth <br /> f Character of soil to a depth of 3 feet: — \ <br /> IE Capacity'y No. Compartments <br /> El TANK Type/Mfg Method of Disposal <br /> I PKG, TREATMENT PLT. ❑ r <br /> Distance to nearest: Well ' Foundation Property Line <br /> LEACHING LINE LR' No. & L ngth of line _-, Total length/size �-� <br /> FILTER BED El Distance to nearest: Well C Foundation Property Line <br /> r� Number <br /> SEEPAGE PITS l Depth Pyr J Size <br /> SUMPS ❑ Distance to nearest: we'llL7/ Foundation 70 r Property Line <br /> k DISPOSAL PONDS f ❑ state laws, and <br /> - <br /> i�hereby certify that I have prepared this application and that the work will be done in accordance-with San Joaquin county ordinances, <br /> rules and,r" ulations of the San Joaquin Local Health District- Y <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 /> signature <br /> employ any person iri such manner as to become subject to workman's compensation laws of California."Contracgvnslsubjectlng rt woorkman'Is9ompensa <br /> F f certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ p <br /> t tion laws of California." t <br /> The applica t must all for ail quireid inspections. Complete drawing o arse side. <br /> Signed X <br /> Title: 6rlwlDate: <br /> FOR DEPARTMENT USE ONLY <br /> r _ Pate rel <br /> f <br /> OPtication Accepted by or Grout Inspection by <br /> Oate 7 Final Inspection by Date y <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> ffW9 <br /> AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> 1 <br /> j + EH 13-24 IAEV.t/r 51 ® %�.],n bEH 14-2e <br />