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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT t <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> L 1/ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District foraermit to construct and/or install the work herein described.P sc bed. Th1s 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 /> L c <br /> Job Address ✓ "e�. City ,4 Lot Size <br /> Owner's Name ` �/l.� Address r Phone I <br /> Contractor lezg[ Address q � License No. 4/1J� 2- I ffJr <br /> Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ 1 WELL REPLACEMENT ❑ DESTRUCTION © i <br /> �` +- "�"PUAIP'iNSTALLA710N=❑ Vim" " + SYSTEM-REPAIR 4OTHER,Q__,— <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> rt <br /> t <br /> r INTENi}ED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑,Industrial' ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ; %Specifications <br /> 1`7 Public F1 Other F1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation --Approx. Depth i I Eastern •. Surface Seal Installed by n _ <br /> Repair Work Dane ❑ Type of Pump H,P. State Work Done\ r <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50'i ' - <br /> Depth Filler Material (Below 501 ' `n <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is it 1 1 <br /> k . —ts <br /> ;s ;""ailil ble v?ithitf200'feet.) f <br /> l <br /> Installation will serve: R sidence' `N Commercial Cher q i <br /> 1 <br /> Number of-living units: Numberbedrooms�*�+ <br /> Charactef.of soil to a depth of 3 feet: �`" --•v yam+'. t Waterjable depth \ <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. CompartmentsPKG. TREATMENT-PLT. ❑ Disposal— <br /> Distance <br /> r/ Method of Disposal <br /> R <br /> f Distance to nearest: "Well ' Foundation._._-.� Property Line <br /> LEACHING LINE ❑ No. & Length of lines !� f #. ,r�T,otal length/size d{ - <br /> FILTER BED,, r ^� 0 Distance to nearest: V1+e11 �Founda�ion—, � Property.Line�-'e ' <br /> SEEPAGE PITS l 1 Depthze t r� Number <br /> SUII Distance to nearest: Well G�-� FqundationI Property Line <br /> DISPOSAL PONDS ❑ <br /> I Hereby certify that I have prepared this application and that the work will b6-done-in accordance w__i_th_San_Joaquin-county ordin8ncesstate laws?"and <br /> rules and regulations of the San Joaquin Local Health District. ,i► :x; t 1. �`'I p) <br /> Home owner or licensed agent's signature certifies the following: "I certify`that in the performance of the Ework for which this permit is issued, I shall not k <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,I shall employ persons subject to workman's compensa- <br /> tion laws of California." d <br /> The applicant must far all requ' d inspectio amplete drawing on reverse side. k <br /> Signed X rtle: <br /> Date- <br /> t FOR DEPARTMENT USE ONLY �} <br /> Application Accepted byw Data Arae �e+C x <br /> Pit or Grout Inspection by bate Final Inspection by bate 0„ <br /> Addilional_Comments: '" t <br /> ❑`stk 67 <br /> 466- 81 _ ❑ odL ice' 369=3621—0-Mantecii-8237104 p-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 /> FEE <br /> INFO AMOUNT DUE AMOUNT R`E�Mrr-TED ASH RECEIVED 9Y DATE PERMIT-NO. <br /> +.EH 1 <br /> 3-211REV.iiH51 vv Tyr (hy <br /> EH 14-29 <br />