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r ' <br /> •,- APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. <br /> HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Appl+cation is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described•This aPd'Joaquin <br /> 'a"s <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1862 for well/pump and the Rules and Reg p I,'1 It^ <br /> ], P� V tR <br /> Local Health District. <br /> Z� _l�l1S -- Lot Size PM <br /> 2 � 3 <br /> Job Address . City <br /> e _ "� d <br /> Address �ZZfc 3hone <br /> Owner's Name <br /> -- <br /> 4 Phone <br /> Address <br /> _ <br /> Address_1� a se No._ <br /> Contractor ---- WELL REPLACEMENT DESTRUCTION C <br /> TYPE OF WELL/PUMP: NEW WELL <br /> SYSTEM REPAIR C DISPOSAL FlD.2,�LOTHER u <br /> PUMP INSTALLATION � PROP. LINE <br /> — , <br /> DISTANCF TO NEAREST: SEPTIC TANK SEWER LINES <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> FOUNDATION _— -- M <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO�N�S Da of Wall Casing 1 <br /> Industrial � Open Bottom Manteca Dia.of Well Excavation7-:.-=-' � <br /> Tracy Type of Casing_��- <br /> Swft1� <br /> X Domestic/Private Gravel Pack A-0 / Typ of Grout <br /> Public Other Delta Depth of Grout Seal <br /> Irrigation __ Approx. Depth Eastern Surface Seal Installed by <br /> T of Pump _- H.P. _ State Work Dona u� <br /> Repair Work Done �_- Type ----- � <br /> Sealing Material Itop 50'1 <br /> Well Destruction Well Diameter _- ---- Filler Material(below 50'1 <br /> Depth--- -- — iNo septic system permitted if public sewer Is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION DESTRUCTION available within 200 feet.) <br /> Installation will serve: Residence_ Commercial —_ Other —_— <br /> Number of living units: _— Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: ___ _ Capacity No.Con",tmer+ts <br /> SEPTIC TANK C Type/Mfg Method of Disposal <br /> PKG.TREATMENT PLT,CI Property LineI, Distance to nearest: Well_ Foundation <br /> Total length/size i <br /> LEACHING LINE ❑ No. & Length of lines _— Foundation -- Property Line <br /> — <br /> FILTER BED U Distance to nearest. Well <br /> ------Size Number a' <br /> SEEPAGE PITS Ci Depth _--- --- Foundationw Property Line a' <br /> SUMPS Ll Distance to nearest: Well <br /> DISPOSAL PONDS ' <br /> lication and that the work will be done in accordance with San Joaquin county ordinances.tttets�'and <br /> I hereby certify that I have prepared this app � <br /> rules and regulations of the San Joaquin Local Health District. is jawed,1 shah not <br /> Home owner or licensed agent's signature candies the following: "I certify that in the performance of the work for which this permit <br /> employ any person in such manner as to become subject to workman's compensation laws of ed,CaliI shall Contra ars'ns subject <br /> u � ob�� compares- y <br /> certifies the following:"1 certify that in the performance of the work.or which this permit k issued,1 shall employ Dere <br /> tion laws of California." <br /> The app) n must gall for at uired spectio C plate drawing on arsee dd <br /> 77D�t! 'ITt :___----1c�t.�11LJ Datr. <br /> Signed _�_ -'---— -. <br /> f FOR DEPARTMENT USE ONLY L. <br /> — � DateL/ <br /> '9— O I A. <br /> Application Accepted by Data /U Za J <br /> Pit or Grout Inspection by <br /> ! Date 0•_ Final Inspection by <br /> Additional Comments: <br /> Stk 466-6781 G Lodi 369-3621 G Manteca 823.7104 . Tracy B3re., <br /> M_ P.O.Applicant-Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P. Box 2009,Stk.,CA 96201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> . EH 17'Y4 IRkV.+ "^ <br /> 3 . 111930 Its �t <br /> EH 14,26 <br />