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Y � , <br /> APPLICATION FOR PERMIT <br /> SAN JOAO.UIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL—I ON AVE.,STOCKTON, CA <br /> 3 Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED <br /> (Complete in Triplicate) j <br /> all the work application is f <br /> Application is hereby <br /> with de Sanothe Joaqu nn County ordinance No.District Joaquin Local Health 549 for sewage or permit <br /> No. 1862 for wellldpump atnd the Rules and Regulations of the San Joaquin <br /> made in compliance - <br /> Local Health District. <br /> 11 <br /> iX/ � PM <br /> . <br /> City Lot Size <br /> Job Address „ .:�. :� - <br /> + ' S- J -i Phone b t7 <br /> 1Jel� Address <br /> Owner's Name <br /> _-*--� _ .- -j, �... •j "�E/ / ' t/"'�A; License NaT `JT Phone <br /> Contractor <br /> DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ 4. <br /> SEWER LI DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL <br />'i FOUNDATION <br /> l <br /> INT 6 15 USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> I ❑ Industrial en Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> Tracy Type of Casing <br /> ❑ Domestic/Private ❑ Gravel Pa th of Grout Seal Type of Grout <br /> ❑ Public F El Other L [I Delta <br /> ' x. Depth. ❑ Eastern Surface Sea <br /> k <br /> L3 irrigation ��#ppro <br /> , State Wor <br /> Repair Work Done L3H.P.Type of Pump Sealing Material flop 50'1 <br /> Well Destruction C] Weil Diameter Filler Material)Belo 50'1 <br /> Depth111112, <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ availablelwit in 200 feet.) if public sewer is <br /> Installation will serve: Residence Commercial Other T { <br /> Number of living units: Number of bedrooms a-- Water table depth <br /> Character of soil to a depth of 3 feet: r <br /> I #j Capacity z No. Compartments I <br /> d SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ h A/VAe -Foundation_°'�/v_r_L`Property Line" <br /> r Distance.to nearest: Well <br /> --� Total length/size <br /> LEACHING LINE No. &Length of lines — property Line <br /> I FILTER BED R ElIr Distance to nearest: Well <br /> 01✓e Foundation ; <br /> Size _ Number <br /> SEEPAGE PITS ❑ Depth a ti I'll I- , Foundation Property Line <br /> j SUMPS �. _❑ Distance to nearest: Well —� — <br /> t DISPOSAL PONDS LJr <br /> I ave prepared this application land that the work will be done in accordance with San Joaquin county ordinances, <br /> I hereby certify that I hstate laws, and <br /> rules and regulations of the San Joaquin Local Healih District. <br /> C Home owner licensed <br /> ice nseuc hmanne signature <br /> as to becomes the following: <br /> olbject llo workman's compensation lawsoof Californian"Contract which shiringl or sub-contracting I signature <br /> employ y person <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 /> The applicant must call gr all required inspections- Complete drawing on reverse side. <br /> f �' Title: Date: , <br /> { Signed X i -- J <br /> ORRDEPARTMENT USE ONLY <br /> Date - Area <br /> Application Accepte y <br /> Final in <br /> by Date <br /> Pit or Grout Inspection by Date ■ <br /> Additional Comme ts: 4 <br /> 11Stk 466-6781 ❑ Lodi 369 3621 ❑ Manteca Se4 E. <br /> Tracy 835-6385 <br /> h permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 <br /> Applicant- Return all copies to: Environmental Healt ' <br /> CK RECEIVED BY DATE PERMIT NO. 5 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO I `8 <br /> + EH 13-24(REV.,/8!5) X70 O� / <br /> EH 14-28 i <br />