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s <br /> APPLICATION FOR PERMIT <br />! SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1"YEAR FROM DATE ISSUED <br /> _ 4 _ <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 Rules and Regulations of the San Joaquin <br /> Local Health District. "1�� r <br /> Job Address 5~� Cit � /A N <br /> Y rLot Size PM <br /> Owner's Narn.. ; 167; Address Phone <br /> Cvntracor l I'V& Address 600 Le►e d .P9vd�STa <br /> License No. Yy-"B�j�Phone"S��`"���1'J ! <br /> TYPErOF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑' " DESTRUCTION EJ + F <br /> PUMA INSTALLATION ❑ SYSTEM REPAIR ❑T OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. <br /> FOUNDATION. AGRICULTURE WELL PROP. LINE <br /> OTHER WELL PITS_ <br /> /SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Ind#stria! ❑ Open Bottom L] Manteca Dia. of Well Excavation <br /> t, Dia. of Well Casing <br /> -❑ Dorrlestic/Private, ❑ Gravel Pack" ❑ Tracy n Type of Casing Specifications <br /> Fl Public C Other ";1171 DeltaDepth of Grout Seal_- Type of Grout <br /> i I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by i <br /> Repair Work Done ❑ ,-type of Pump H P ; -.3at <br /> - State Work Done'— � <br /> *WeII Destruction .-❑ Well.Diameter Sealing Material {top 50'1 j <br /> 1t Depth Fillet µ " — -_ "" _ - -arae ► ' <br /> TYPE OF SEPTIC WORK`. NEW INSTALLATION Y1 REPAIR/ADDITION i.l DESTRUCTION E I (No septic`system permitted if public sewer is <br /> 4 <br /> �,, r. °available within 200 feet.)' ' <br /> Installation will serve: `Residence j Commercial Other + '+= r <br /> Number of Living units:' ._''Number of bedrooms <br /> Character of soil to a depth of 3 feet: t �� Ag 4 Waterrtable-depth 4 s <br /> 'SE PTIC TA�Nk YJ T elMf I Av T <br /> yp g S Capacity—Z-470 No. Compartments .� <br /> FKG, TREATMENT PLT. ❑,, Method of Disposal <br /> Distance to{nearest: Well 1- BO" Foundation 10 Property Line -� <br /> LEACHING LINE ON 'No & Length of lines Total length/size <br /> FILLER BED ❑ Distance to nearest: Well:, Foundation Property Line -- _ <br /> SEEPAGE PITS I'I Depth �'~ Size yx , 6' ' <br /> r��Xlumber A <br /> SUMPS Ill.°t Distance to nearest: Well Ece • _ Foundation 2 0 Property Line 5 <br /> DISPi7SAL PONDS ; ❑`'i` � Y F �- <br /> 4 <br /> I hereby certify`that I have prepared this application and that the work will be done in accordance with-San Joaquin coup y ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. _ <br /> Home-owner or li ensed'agent's.signature certifies the following: "I certify that in the performance f the work for which this permit is issued, I shall not <br /> empioy 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'tha 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 Califor <br /> The applicant t a t for 1 re ad " ctions. CgrtlpTete drawing on reverse side. <br /> Signed X .° // Tide. ©ceiyey <br /> bate: 'V~ <br /> Y , J <br /> FOR PARTMENT USE ONLY <br /> Application Accepted byl v Date _ 5 p <br /> Area t <br /> Pit or Grout Ins ion by Data Final Inspection by <br /> iT Date <br /> Additional Co �� a �` ✓ i <br /> 4:�; <br /> D Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tr <br /> y 835-6385 a' <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2 Stk., 95201 <br /> 1 l <br /> tM!tt <br /> `�!FEE <br /> INFO AMOUNT DUE .t- AMOUNT- �s GATEPERMIT"NO. <br /> tH,a-s.IREv.,,nsl �Q / OEH 14-28 <br />