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.4- <br /> APPLICATION FOR PERMIT <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 1• <br /> F.(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 h" r <br /> made H compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of t <br /> Local Health District. and <br /> R described. This application n <br /> he San Joaquin <br /> Job AddressCek <br /> City ® � <br /> t - Lot Size PM <br /> :Owner's Name Q � <br /> _`.. Address <br /> "Contractor / Phone <br /> S <br /> TYPEOF WI1W r-UMP: Address <br /> NEW WELL ❑ License No. y❑UMP-INSPhone € <br /> TALi_ATION7.0 WELL REPLACEMENT <br /> _ 'bESTRUCTION ❑-'> .. ;,. <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR D- - - -`� <br /> —� SEWER LINES OTHERY❑=�� <br /> � DISPOSAL FLD, <br /> FOUNDATION t PROP. LINE <br /> -�� AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA PITS/SUMPS <br /> ❑ Industrial -�� CONSTRUCTION SPECIFICATIONS <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation•"3" . r <br /> ❑ Domes`tic/Private � - `� <br /> _s k /D,Gravel Pack ❑ Tracy Dia. of Well Casing' ' I <br /> ❑ Public Ap "s; Type of Casing '" , ° <br /> �❑ Other ❑DeltaSpecifications�; r' <br /> ❑ IrrigationDepth of Grout Seal <br /> -2-Approx. Depth ❑ Eastern Surface Seal Installed by Type of Grout <br /> Repair Work Done ❑ Type of Pump <br /> Well Destruction H.P. State Work Done <br /> ❑ Well Diameter - 4, <br /> Se`a�ng Material (top s0'E' <br /> Depth'" <br /> TYPE Filler Material (Below 50') <br /> OF SEPTIC WORK: NEW+IN57ALLATION REPAIR/ADDITION Q DESTRUCTION ❑ IN septic system N <br /> Installation will serve: Residence y Permitted if public sewer is <br /> ` ""` " available within•200-feet' <br /> Commercial Other_�� " '""" "" �-" --.-� ~•(� <br /> Number of living units: uNumber of bedrooms <br /> Character of soil to a depth of 3 feet: ' <br /> - ,5� _ P <br /> SEPTIC TANK '� "Water table depth= <br /> �TyPelMfg <br /> PKG. TREATMENT PLT. ❑ F Capacity N6.aCOmpartmen <br /> Distance to nearest: Wel( "Method of Disposal <br /> 4.�. <br /> p, Foundation. � Property Line <br /> LEACHING LINE i` <br /> No. 8& Length of lines '7 <br /> FILTER PED # ❑ Distance to nearest: Well Total length%sizes 51 <br /> " 4 - Foundation 4 <br /> '"`- �:�,-•� ;?� � - � Property,Zne 1. <br /> SEEPAGE-PITS Q "Depth (� " <br /> SUMPSP 'Sizes '~ Number <br /> LO;Z­Distanice.to-nearest:4� WeII Y> - <br /> DISPOSAL PONDS Imo❑ ` 'Foundation Property Line <br /> I hereby certify that I have prepared this application.and that the o k.will be done.in"accordance:iivith San",Joa'urn county ordinances, state laws, and4.1 <br /> rules and regulations of the San Joagijn,Local Healtfi'•District. f, �e •�'` - J w ' <br /> Home owner or licensed agent's signature certifiasthe,followin .w <br /> the <br /> employ any person in such manner as to become:subiect to.wok ah'srtcompi3nsation Laws of Califonce�niathe <br /> "Contractors+hiringthis <br /> opsub cont acenglsignashall <br /> tu�e ' <br /> certifies fhe following: "I certify that in the Performarice of the work for which thisl ermit is issued, I shah e' Io <br /> tion laws of California." P employ persons subject to workman's compensa- <br /> 4 ..f. } _7.. ° r <br /> The appUca ust cal!for II equir inspections. Camp e`tetdrawingn reverse side. . w <br /> Signed X f" <br /> Title: eJ <br /> Date: <br /> :.f FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> 4 ., f G � <br /> Date - <br /> Pit or Grout InspeArea <br /> cti " ' ` ; <br /> DateFinal Inspection b <br /> DateG� 0 <br /> Additional Comments; " <br /> b . .i . <br /> ❑ Sic t466-6781- Return <br /> ❑ Lodi 368-3621 y s❑ Manteca".823-7104 �e❑'Tracy 835,6385 <br /> Applicant- Return all copies to: Environmental HTTealth Permit)Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE <br /> INFO AMOUNT REMITTED CK 'RECEIVED BY <br /> j1DTE PERMIT NO. <br /> r EH 13-24{REY.t i w 5Y <br /> "r� <br />