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,ply APPLICATION FOR PERMITT <br /> � SAN JOAQUIN LOCAL HEALTH DISTRICT PAYME T' <br /> �� <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA RECEIVED <br /> Telephohe 12091 466-6781 MAR O '�� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IComplete in Triplicate) ENVIRONMENTAL 14E,4 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal the apppwtion b <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ruegulat of the San Joaquin <br /> Local Health District. <br /> Job Address A O W� WEALS& Am& City S rot Lot Size A C-Rrx PM <br /> Owners Name Il it]10 AJ =G - Address Phone A <br /> 31 <br /> 4StEd 8+6�eG f {2u/0 <br /> Contractor_ST t -- Address2"3 tlfl1S-r RDIt141?6_.0 icenseNa.� ?O Phone r7-,V767 <br /> TYPE OF WELL/PUMP: NEW WELL 1K WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -2S DISPOSAL FLD. PROP. LINE _r!� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL-,k PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> (j Industrial fnr•N rrtoK© Open Bottom ❑ Manteca Dia. of Well Excavation 4- 12 Dia. of Well Casing <br /> Domestic/Private CI Gravel Pack ❑Tracy Type of Casing_fK # 17A/&Vt-jf Specifications <br /> 1'1 Public �c Other Fl Delta Depth of Grout Seat 1� 6 <br /> Type of Grout ��►'_nr d <br /> I I Irrigation .'� Approxb. Depth I I Eastern Surface Seat Installed by reC4 _ <br /> Repair Work Done ❑ Type of Pump State Work Done_ <br /> Well Destruction ❑ Well Diameter 41"ANAL M Sealing Material(top W <br /> ' at <br /> Depth A 0 i- A-V. - 6,_ Filler Material (Below SO') _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available within 200 feet.) 111 <br /> Installation will serve: Residence— Commercial_ Other N <br /> er <br /> Numbof living units: Number of bedrooms t 5 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity-- No. Compartments <br /> PKG.TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Welln�j— Property Line <br /> T--::S1Aft - "'N 41 <br /> LEACHING LINE CI No. 8 Length of lines Total length/size l <br /> FILTER BED ❑ Distance to nearest: Wel .-- Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS I-I <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 /> nils and regulations of the San Joaquin Local Health f•7r'ktrict. <br /> Horns owner or licensed agent's signature certifies the following: "I certify that to the performance of the work for which this permit is issued. I chap not <br /> employ any person in such manner as to became subject to workman's compensation Iowa of CaMorrio."Contractors hiring or sAvcontreedng signettxe <br /> certifies Ow following:'1 certify that' the performance of the work for which this permit is issued,I shall employ persons subject to workman's compersa- <br /> tion krws 'ornia." <br /> The Wtioons. Complete drawing on rse 'de. <br /> Sigrbd <br /> Title: Date: 3 -116— <br /> FOR DEPA16M7 E ONLY <br /> Application Accepted by __._.. Date Area <br /> Pit or Grout Inspection by ` Date Final Inspection by � . .� Date <br /> Additional Comments: <br /> ❑ Stk 40B-6781 ❑ Lodi 369-3621 ❑ Marrteca 823-71104 ❑Tracy OW6305 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 16D1 E. Hazelton Ave., P.O. Box 2009, S1k., CA 952D1 <br /> FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED 8Y DATE PERMIT'NO. <br /> INFO <br />�.EN W lntv.,,eb, 110 sa <br /> �► yob <br />