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APPLICATION FOR PERMif <br /> - — SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL I ON 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 Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> City.!?jOC >76) Lot Size 3 G PM------ <br /> Job Address - <br /> ,� U Stdc .516/ Phone <br /> owner's Name -- F S 21 Lit ii21� Address -cL" <br /> ail re dEocrU 4. AldfIvflZo a s ori <br /> Contractor � t' Address <br /> 3 '• <br /> X41 • } License No. a Phona---> <br /> TYPE OF WELL/PUMP: NEW WELL;9 WELL REPLACEMENT ElDESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES 5�.�i# f%ISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 7 Industrial 01 r„►1 rc ❑ Open Bottom ❑ Manteca Dia. of Weg Excavation <br /> Dia. of Wall Casing 1 3 <br /> 9.c, a t- P !rG � u s Specifications <br /> ❑ Domestic/Private EI Gravel Pack ❑ Tracy Type of Casing <br /> Delta Depth of Grout Seal S Type of Grout c:J*n --- <br /> I"1 Public 90ther -P +6t ' <br /> I I Inigation -__Approx. Depth l l Eastern Surface Soul Installed by <br /> Repair Work Done U Type of Pump 1-4-9--- 11-P. --- State Work Done <br /> Well Destruction ❑ Well Diameter -AL1 'I,Zrr Sealing Material Itop 50'1 — )j <br /> Depth • o` filler Material Welow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I RFPAIR/ADDITION I I DESTRUCTION i 1 lNo septic system permitted if public sewer is s <br /> availab Tl <br /> Installation will serve: Residence— Commercial-- Other <br /> Number of living units: Number of bedrooms w <br /> Character of soil to a depth of 3 feet: Water table depth r <br /> SEPTIC TANK L I Type/Mfg __ Capacity No. &RAngnitsiggg , <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Propertt,ltn <br /> LEACHING LINE CI No. & Length of lines Total length/size <br /> FILTER BED El Distance to nearest: Well _ Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS t_1 Distance to nearest: Well_ Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 DiLtrict. <br /> Hoe owner or licensed agent's signature certifies the following: "I certify that in the performance pe <br /> of the work for which this rmit is issued <br /> Horne . I"not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:"I c"fy that in the performance of the work for which this permit is issued,f shag employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must all for g re ►'ad inspections. Complete drawing on reverse side. <br /> 3 <br /> Signed X r � Title: ��-H..W.-- pate: �Pk 14 <br /> // F. DEPAR USE ONLY <br /> Application Accepted by �w- Date Area <br /> Pit or Grout Inspection by Datep^K Final Inspection by Data <br /> Additional Comments: ? /r't - / �� <br /> ❑ Stk 466 6781 ❑ Lodi 369-3621 ❑ Manteca 823.7104 d Tracy 8354M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 9=1 <br /> FEE AMOUNT DUE AMOUNT REMITTED XS RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> a EH 13-241REV.r/�51 Sal� <br /> rk <br /> ! $q 13 <br />