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APPLICATIONFORPERMIT <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 /> 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 Rul$s and Reggl i�s of the San Joaquin <br /> Local Health District. t1/IV Pp/lit-772- <br /> W <br /> lob*Ads sw <br /> ..� City S T1 Lot Size <br /> Z,S�2 Iry CL rWPhone <br /> Owner's Name `� '`~�" ddress <br /> %'`` : a se No. Phone <br /> I ContFadtor's Name <br /> TYPE OF WELL/PUMP: ' °NEW WELL k" WELL REPLACEMENT DESTRUCTION ❑ 2� <br /> MP INSTALLATION ,#SYSTEM REPAI ❑ .}.OT R�l <br /> � r PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANWt�—SEWER LINES DISPOSAL FLD. <br /> FOUNDATION AGRICULTURE WELL OTHER <br /> WELL—PITS/SUMPS <br /> _- INTENDED USE TY E OF WELL. °` 'PROBLEM AREA...,•.CONSTRUCTION SPECIFICATJ ' <br /> ❑ Industrial en Battom'-�--.,❑.Manteca Dia. of Well Exca tion % Dia.~of ell-Casing,. <br /> zzlT e of Casing Specifications <br /> ❑ Domestic/Private Gravel Pack ❑ Tracy YP 9 H.. ._.- <br /> ❑ Pu ❑ Other ❑,Delta Depth of Grout Seal, / t � . Type of Grout <br /> — <br /> 0 <br /> f _�Approx h Ea'tern Su l Installed by R <br /> Repair Work Done ❑ Type of Pump � � H.P. + — State Work Done <br /> Well Destruction x ❑ Well Diameter Seaing Mafeiial'[top"50'M "' - - -- —�-- <br /> ` � Depth T Filler Material (Below 501 Q <br /> TYPE OF SEPTIC WORK: INEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is <br /> available within 200 feet.) m <br /> Installation will serve: Residence. Commercial_ Other <br /> Number of living units: aNumber of bedrooms -� <br /> Character of soil to a depth of 3 feet:, Water table depth (0 <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> f PKG. TREATMENT PLT. ❑ 1 Method of Disposal <br /> t Distance to nearest: Well Foundation Property Line �} <br /> F <br /> LEACHING LINE ❑ No. & Length of lines ' Notal length/size <br /> I FILTER BED ❑ Distance to nearest: Well ` ''Foundation Property Line / <br /> SEEPAGE PITS ❑ Depth ' t Size Number <br /> k <br /> SUMPS ❑ 'Distance to nearest: Well Foundation Property Liner <br /> DISPOSAL PONDS ❑ F "X <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joalin county ordinances, state laws, and <br /> I + rules and regulations of the San Joaquin Local Heal lth District. 1'r <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performancerof the work for which this permit is issued, I shall"not <br /> employ any person in such manner as to'become ubject•to v✓orkman's compensation laws of California."Contractor's hiring or sub-contracting"signature <br /> certifies the following:"I certify that i e performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." L <br /> The applica` u call r all ui ' s c mplete drawing-on relerAside. <br /> ' ned' - Title: _ Date: <br /> !Sig � <br /> FOR DEPARTMENT'U5E ONLY <br /> i 1 Area Q <br /> i(Sl�Z Date <br /> Application Accepted by <br /> Date <br /> 'Pit or Grout Inspection by �"° "£ `� Date �Finai Inspection by_ <br /> oe� 4Z <br /> Additional Comments: n T <br /> Stk 46G M1----' Lodi 369-3621 El.Manteca 823-7104 ❑ Tracy 835q335 <br /> plicant-- Return all copies to:..Environmental"Health PermitlServiees 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 .ScG . <br /> FEE, AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY: DATE PERMIT:NO. <br /> I F0 S 3Z3 —p <br /> +EH.13,24IREV.10183) Qr` <br /> E11 14-26 1 F <br /> I <br />