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t <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE„ STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM-DATE, ISSUED <br /> (Complete in Triplicate) <br /> all the work herein <br /> cation is <br /> j made in ion is heieb made to the Sin Can ounty Ordnance No 549 for sewage or uin Local Health District for a permit <br /> No. 1862 for cwell/dpOmp atnd the Runes and Regulations described.of This <br /> lhe Sant Joaquin <br /> ance <br /> Local Health District. <br /> �� _ City Lot Size=��'�s-�— PM <br /> Job Address -`= <br /> ` ra� _ Address Phone <br /> Owner's Name n 9 _ <br /> % �c 7,3o? Phone <br /> Contractor <br /> Address / D �6'1'C 3Sa� License No. -- <br /> TYPE OF WELL/PUMP: ..� _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> �_J PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> t SEWER LINES DISPOSAL FLD. — PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK _ — . OTHER WELL_ PITS/SUMPS <br /> l ' FOUNDATION AGRICULTURE WELL _- <br /> \>JNTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ilndusirial i �� O Open Bottom ❑ Manteca Dia. of Well Excavation <br /> r Type of Casing_ _ Specifications <br /> ❑!DomesciclPrivate � ❑ Gravel Pack s ❑ Tracy Type of Grout__— <br /> T'14Public ❑ Oti ❑ Delta Depth of Grout Seal yP <br /> i'!hrrigauon t ,_Approx. Depth `I 1 Eastern Surface Seal Installed by <br /> t State Work Done <br /> Re6ir Work Done € ❑ Type of Pump - H.P. <br /> Well Destruction ❑ Well Diameter Sealing Material ltop 50'! <br /> j Depth Filler Material (Below 501 1 , <br /> TYPE OF SEPTIC WORK: NEW INST�AL�LATION REPAIR/ADDITION t I DESTRUCTION i ' aNailabo septicle systeithin200 1 pe e itted if public sewer is <br /> ! Installation will? serve; i Residence t! t.ommercial` Other <br /> Number of living units: Number of bedrooms <br /> I Character of so it to a depth of 3 feet:( Q£— Water table depth�� B <br /> SEPTIC TANK -❑ Type/Mfg ` a') Capacrty_f�s�- No. Comparunents . <br /> PKG. TREATMENT PLT. ❑ i Method of Disp pal <br /> Distance to nearest: Well �//9�— Foundation_f2_-_—.Property Line _�0 <br /> LEACHING LINE Leo. & Length of lines --..�_- T9tal length/size. _ - C <br /> '� \ <br /> FILTER BED') O Distance to nearest: Well /(LtZ Foundation_�� Z'— Property Line- !�O — <br /> SEEPAGE PITS I--I�Depth pL-ir Size 'L-- Number �T <br /> r ��`O Foundation 199 "t Property Line <br /> SUMPS Ll 'Distance to nearest: Well�t— <br /> DISPOSAL PONDS" C, <br /> I hereby certify that') hale prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and <br /> rules and regulations of the San.Joaquin Local Health District. <br /> Home owner'or licensed agent's signature certfes 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 workmen's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the followin 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 /> 9 �� <br /> tion taws of Cal' a. <br /> i 1 <br /> The applican mus call fo Lrequir nspections. Complete drawing on reverse side. <br /> j Signed Title: Date: <br /> _ tAll <br /> FOR DEPARTMENT USE ONLY <br /> i I Date Area <br /> Application Accepted by - �o�Oti-C/� <br /> 1 Pit or Grout Inspection b •^ bate ' Final Inspection by Z Date 2 <br /> Additional Comments: <br /> LJ Stk 466.6781 El Lodi 369-3621 ❑ Manteca 92371041A�,' ❑fTracy 8356i65 <br /> ,_,._Applicant—Return_all.copies-to:.Environ mental-Health_P_eimit/Services 1601 E. Hazelton Ave., Box 2009, Stk., CA 95201 •_ <br /> FEE CK RECEIVED BY', PATE PERMIT NO. <br /> INFO {AMOUNT DUE AMOUNT REMITTED CASH RQ <br /> ( ..EH 13-2�tREV.liNsl 1 O��� �1 / � •�• Y '�•� - IJ✓`'' (JtJ _��� <br /> EH 1418 1 <br />