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APPLICATION FOR PERMIT <br /> . .+k c.✓'s 5 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEI_TON AVE., STOCKTON, CA { <br /> g. <br /> Telephone-(209)I 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED" <br /> (Complete 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 Ryles and Regulations of the San Joaquin <br /> Local Health District <br /> ` City LotiSiz PM i <br /> f Job'AddreSst <br /> "er J Phone ` Y <br /> Owner's Nam Address <br /> ContraJaL <br /> Address ® License No. hone <br /> TYPE OF WELL/-PUMP: . NEW WELL ❑ WELL REPLACEMENT EJ DESTRUCTION ❑ <br /> -_J PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER 11 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL'FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL ' PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial 110- <br /> n,peBottom C: Manteca 0=a'V1�ell Excavation) Dia. of Well Casing <br /> of Casing Specifications <br /> El Domestic/Private 7-1Gravel,Pack El Tracy. Type 9. .' <br /> f } �G , I <br /> i Type of Grout <br /> ❑ Public ❑ Other 171 Delta Depth orour <br /> �' pprox `Depth `3-Eastern Surface 5eal,lnstalled by <br /> 13 Irrigation <br /> VI <br /> ��+ H.P. State Work Done = <br /> Repair Work Done ❑ Type of Pump _ r <br /> Sealing Material (top 50'1 `' s <br /> Well Destruction E ❑ %Well Diameter 9 { z I <br /> Depth;- er§Material-{$slow <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION'Q, REPAIR ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> �- l available within 200 feet.) <br /> _ <br /> Installatior , <br /> iwill serve: Residence�Commercial Other,f� � � <br /> Number of+living units: i Number#bedrooms <br /> vAO a w�v� Water-,table depth <br /> . Character of soil to a depth 1.1\of 3 feet;' ■■-�--y # c <br /> SEPTIC TANK EI ype/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ v Method of,Disposal i <br /> Distance to nearest: Well Foundation Property Line, _ <br /> LEACHING LINE [_1 No. &Length of lines Total length/size <br /> r j <br /> FILTER BED ❑j�Distance,to,,nearest: Well Foundation Property Line. ` <br /> � r- ..� ?_J a _" �� Number i <br /> SEEP <br /> PAGE'PITS'+' ""1L� Depth '` - <br /> SUMPS� ,R ❑ Distance to nearest: Well/l�®` Foundation—/'�� Propertq Line^S <br /> DISPOSAL PONDS ❑ { <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin.county ordinances, state laws, and ' <br /> r rules and regulations of the San Joaquin Local Health District. ' <br /> Home owner or licensed agent's signatdre certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> lay any person in such manner as t <br /> empo 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." , ­_ ...�. <br /> _ <br /> ., T.he_applica ust.call f I,.re iredinspections.-Complete.drawing on-reverse id e....�,....,.--- --- <br /> Title: Date: _. 57 <br /> Signed <br /> f FOR DEPA TMENT USE ONLY <br /> ._. ... "Date <br /> v "� "- "Area . — --•-- <br /> gppliZatiotn-Accepted"by f <br /> Pit r Grout Inspection by Date <br /> inal Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 111 Lodi 369-3621 ❑ Manteca $23 7104 El 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 /> CK# RECEIVED BY DATE PERMIT"NO. <br /> IFEE s NFOTAMOUNT DUE AMOUNT REMITTED CASH <br /> 4 + EH 13-24(REV.1/85 , <br /> Eli 14-26 . ,,, <br />