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,���-T-_- �,;-•Y/--��.-ter.—� f . <br /> x <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELFON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> A herein <br /> .This <br /> cation <br /> t and/or <br /> the wo <br /> all <br /> Application <br /> is hereby <br /> with to the Sian Joaquin n County Ordinalnce No.549 for sewage or permit <br /> 1862 for cwell/pump aatnnd the Rules and Regulations of the <br /> madeHealth District for a Sant JoagLin <br /> Local Health District. - n 47,r-A2�/ Qifwder <br /> � R1 z�' 99 City " ' / LotSize afliaQwL-+-�--- PM <br /> b�Address �� ,r � � r7 <br /> S S <br /> /� /� �•s Phone Z <br /> Owner's Name l it�T / �' Address <br /> Phone <br /> Contractor a. Address <br /> License Nogis <br /> . - <br /> NE ELL LJ REPLACEMENT ❑_�,,,,,,, :D.FiSTRUCTION.,❑��w /�.''1oN.< .a�:[Ut <br /> TYPE OF_ WE_ELL/PUMP_ SYSTEM REPAIR El <br /> ❑ <br /> PUMP INSTALLATION ❑ <br /> SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> E TO NEAREST: <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> DISTANC <br /> FOUNDATION t <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S <br /> /eljy Dia. of Well Casing r/ —S <br /> C3 Industrial ❑ Open Bottom ❑ Manteca Dia. of ,Well Excavator Specifications Scd-ao <br /> ❑ Gravel Pack ❑ Tracy <br /> Domestic/Private Type of Casing i <br /> � ❑ Delta Depth of Grout Seal Type of Grout <br /> r Public ❑ Other n&vj 1,0" <br /> .Apprgx. Depth I I Eastern Surface Seal Installed <br /> 1 1 Irrigation — State Work Done <br /> Repair Work Done ❑ Type of Pump H.P. <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 .3 <br /> Depth Filler Material (Below 501 , <br /> N I I <br /> TYPE OF SEP TIC WORK: NEW INSTALLATION Il REPAIR/ADDITION I I DESTRUCTIOavailablelwthino200 feet.) if public sewer is <br /> r <br /> j Installation will serve: Residence_ Commercial_ Other ! <br /> Number of living units: _ Number of bedrooms 1 <br /> Water table depth <br /> Character of soil to a depth of 3 feet: „^ ----Eapacity---+ No. Compartments <br /> - SEPTIC TANK C3Type%Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ - <br /> D nce to nearest: Wei <br /> LEACHING <br /> " Property Line <br /> LEACHING LINE EI No.No. & Length of lines 1 Property Line <br /> I{ FILTER BED [I Distance to nearest: Well Foundation Party <br /> [ SEEPAGE PITS I I Depth Size Number <br /> Foundation Property Line <br /> SUMPS Ll Distance to nearest: Well <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, a <br /> E rules and regulations Of the San`Joaquin Local Health District. } / <br /> Home owner or licensed agent's signature certifies the fallowing: "I certify that in the performlince of the work for which this permit is issued, I shall.r <br /> Ionany person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or orb-contracting signah <br /> certifies the following:"I certify that in the performance of the work for which this permit is fissur4ed,I shall employ persons subject to wgrkmafl 5 Compen: <br /> tion laws of California." ! r S r t q <br /> The applicant must or ail rr ired ins pe 'onplate dirawi t on reverse <br /> f —t Titlei of Date: <br /> Signed X - t , <br /> 1 FOR DEPARTMENT USE ONLY <br /> 1 <br /> Application Accepted by <br /> a DateArea <br /> S Date <br /> "7- <br /> Pit or Grout Inspection by _ pp `Da_ta Final Inspection by <br /> Additional Comments: '� V <br /> ❑ Stk 466-6781 •❑ Lodi 369-3621---0 Manteca-823-7104 _ O Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Haielton Ave -P.O. Box 2009, Stk., CA 95201 <br /> 1 FEE gMOUNT DUE AM�fOUNT REMITTED CASH' RECEIVED 01' `� i1!' ]D.A^T�E PERM•ITjNO. J <br /> i` INFO /l�'�d'Ot47 ii —#X� iT O /� ✓� <br />