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APPLICATION FOR PERMIT 2 T <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT VO <br /> I J <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 /> Appliaton is <br /> n describ . This <br /> cation is <br /> madeein r compliance wierebyitthdSanoJoaquin the nCounty OrdinaJoaquin nce Nto. 549 for sewage or h District for a permit <br /> 1862 for well/pump and the Rules and(Regulations of he San'Joaquin <br /> Local Health District. <br /> Job Address 1/0m ed o AA_ <br /> / Lot Size IOeen;, PM _ <br /> f� t:�20KI/ 'y <br /> Owner's Name • il�f--- Address t Phone_ <br /> ,r r r rI Via., <br /> Contract ' Address 7 License No ` s-2.2.4 Phone <br /> TYPE OF WELL/PUM NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION C1 SYSTEM REPAIR OTHER ❑ 6 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE C <br /> FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ ca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications <br /> 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal - Type of Grout <br /> Irrigation _ rox. Depth 1 I Eastern Surface Seal Installed by -- _ <br /> Repair Work Done ❑ pe of Pump_.- H.P. State Work Done_ <br /> Well Destruction Well Diameter Sealing Material ttop 50') <br /> Depth - - Filler Materi 1 (Below 50') <br /> TYPE O SEPTIC WORK: NEW INSTALLATION I.1 - REPAIR/ADDITI N I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> . available within 200 feet.) <br /> Installation will serve: Residence Z Commercial_ Other d <br /> Number of living units: I Number of bedroo s <br /> Character of soil to a depth of 3 feet996 Water table depth D <br /> SEPTIC TANK ❑ Type/Mfg r Capacity 14IW92 No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well AQ I Foundation 44� Property Line <br /> LEACHING LINE No. & Length of lines Total length/size ` <br /> FILTER BED ❑ Distance to nearest: Well Foundation / Property Line <br /> SEEPAGE PITS I I Depth Size Z 7 Number 3 -' <br /> SUMP LIDistanceto nearest: Well d -Foundation Property Lina - s <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this.application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Dstrict. I /1 <br /> Home owner or licensed agent's signature certifies the following: "I cern that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's c mpensation laws.of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for w iich this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mu call for all requir in�pectiona. Complete.drawing reverse side. q <br /> Signed X Title: Date: 4.2_Z .f <br /> FOR DE rARTMENT USE ONLY <br /> Application Accepted by _/.,fid' — Date Area 1 <br /> Pit or Grout Inspection by Date Final Inspection by Data L r41 <br /> i <br /> Additional Comments: ' <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 <br /> FEE ^"'AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO l <br /> , <br /> ..EM 1]-y IREy.I/x51 <br /> EN 143E "1 r 6)- f �G�I <br />