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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f, <br /> 1601 E. HAZE T ON,AVE., STOCKTON, CA <br /> I Telephone (209) 466-6781 /' V <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> � t <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. <br /> f <br /> �9 ��� P• city <br /> Rob Address �— Lot Size 3/4- PM <br /> Owner's Nana Address <br /> C <br /> ' Phone <br /> 3 b'a� do <br /> r 3 f3 <br /> i <br /> ss License No�os 'Zc Phone <br /> Contractor Addre <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT O DESTRUCTION O <br /> PUMP INSTALLATION O SYSTEM REPAIR 11OTHER O <br /> `?DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE " <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> " <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> O Domestic/Private O Gravel Pack ❑Tracy Type of Casing Specifications <br /> Type o! Grout <br /> 11-1 Public 11 Other 11 Delta Depth of Grout Seal <br /> t� <br /> I I Irrigation —Approx. Depth 1 I Eastern Surface Seal installed by <br /> +Repair Work Done ❑- Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter F -� Sealing-M ri 1 <br /> Depth Filter Ma er'al f Below <br /> } TYPE OF SEPTIC WORK: NEW IN5TALLATIO I1 REPASR/ADDITION DESTRUCT N I 1 (No septic system permitted if public sewer is <br /> I available within 200.fe6et.1 f <br /> I Installation will serve: Residence�CommerM: T1 <br /> Number of living units: Number of rooms <br /> l Character of soil to a dept 3 feet: n Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No.Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest* Well Foundation Propdrty.Line <br /> LEACHING LINE &--No.&Length of I' <br /> I Total length/siz 9 <br /> 75 <br /> FILTER BED O Distance to nearest: Wed/ r Foundation — �Ioperty Line _ <br /> 0 <br /> SEEPAGE PITS 14�epth a -Size ' -�7L(�?umber <br /> SUMPS 1<l- Distance to nearest: Wed-_-.ls-zs.� Foundation Property Line <br /> DISPOSAL PONDS ❑ ` <br /> I hereby`certify that I have prepared this application and that the work_ II be done in accordance with San Joaquin county ordinances, state laws, and <br /> F rules and regulations of the San Joaquin Local Health District. <br /> 1 Home owner or licensed agent's signature certifies the fogowinq�."l.ce_rMf(that in the'perfomwnce of the work for which this permit is issued, I shall not <br /> i employ any person in such manner as to bocome suis to war <br /> t kman's compensaL°n taws of Califon-da."Contractors 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 subiect to workman's compensa- <br /> tion laws of California." <br /> The applicant must,call for all equired inspections. Complete drawing on reverse side. <br /> .Signed X <br /> Title:(S/YDate: <br /> FOR DEPARTMENT USE ONLY <br /> F� Area <br /> Ap lication Accepted by Data <br /> it Grout Inspection by yyCf// `� Date } `� Fnal Inspection by Dat <br /> I <br /> i i Additional Comments: <br /> ❑Stk 4&6.6781`- :_LJ.Lodi 3t�3621 _,O Mariieca B23 7107 ❑ Tracy 835 6385 <br /> applicant- Return all copies to: Environmental Health Pemtit/Servicos 1601 E. Hazetton Ave., P.O. Box 2009, Stk., CA 96201 <br /> FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMR NO. <br /> INFO <br /> SH <br /> 1321'{REI/a�iisi VVr4 �� ..si�w ' 4 iy � ,v f: <br /> i'' <br />