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_ APPLICATION FOR PERMIT y ti <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> 1601 E. HAZELTON AVE.', STOCKTON, CA <br /> Telephone 12091 466-6781xr" " VIA W <br /> I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , <br /> ` (Complete in Triplicate) t <br /> { <br /> ii !! ..., f ; I <br /> Application is hereby made to the San Joaquin Local Health District for a permit to,conMruct andlor install the work herein described. TMs application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. i'862,for ell/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> [70 VY LL 2 Qp 'Ci v DrYf 017, .Lot Size PM <br /> Job Address 17, 1}ter >, °l J X11 <br /> i! <br /> fVC>_5 } 0 <br /> 1Cf ; <br /> tiPh.a�n a <br /> V � t <br /> NameT:f Cf Address <br /> Owner's Lr 17- 1` •,` 17 <br /> y <br /> r 'elf <br /> f -1 , 2 !�' <br /> ,�T,, siI License No" 7Phone'­­– <br /> contractor <br /> hone' - <br /> ConlractorrycAddress 1p }I <br /> TYPE OF WELL/PUMP: <br /> NEW WELL 94 WELL REPLACEMENT D_ DESTRUCTION 0_ <br /> �i PUMP INSTALLATION ❑ –,SYSTEM REPAIR'-C7 OTHER ® <br /> DISPOSAL FUD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES`— * f= <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> ( <br /> iN7ENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 <br /> ❑ Inddstrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation root 117 Dia. of Well Casing <br /> E) Domestic/Private Gravel Pack C1 Tracy Type of Casing o ' 4 Specifications <br /> Cl Public Cl Other f-i Deha i Depth of Grout Seal,,rh,s-oX Type of Grout <br /> n <br /> I I Im au .Approx. Depth I I Eastern Surface Seal Installed by ! ^V ! t C 1 r -- i <br /> . . r �, <br /> liep ra18 rbWo k Done U Type of Pump � H.P. State Work Done _ <br /> Well Destruction D Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTIO [No septic system permitted if public sewer is <br /> available within 200 feet.] ! <br /> Installation will serve:. R ce— Commercial Other ! <br /> Number of living unit's: mber of bedrooms <br /> Character of soil to a.depth of 3 tee Water table depth <br /> SEPTIC TANK ❑ t Type/Mfg ,Capacity No. Compartments <br /> f" >3 <br /> PKG. TREATMENT PLT. ❑ lit Method of Disposal <br /> !� isiance to n�eares Well Foundation Property-Line <br /> 4 <br /> LEACHING LINE ❑ No. 8 Length o7tv <br /> Ii Total length/size <br /> FILTER BED ❑ Distance to Well Foundation Property Line <br /> Ei 1 <br /> SEEPAGE PITS I 1 Dept Size Number <br /> SUMPS Ll ante to nearest: WellFo atiw Property Line <br /> DISPOSAL PONDS i? <br /> I hereby certify that I have prepared this application and that the work will be ii l done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify 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 compensation laws of California."Contractor's hiring or subcontracting signature <br /> certifies the following:"I certify that in the perforrtiance of the work for which this permit is issued,i shall employ persons subject to workman's compensa- <br /> tion laws of California." j <br /> The applicant must call f all required inspections. Complete drawing on reverse side. S 4 4 G T) <br /> Signed „n^ r� t Tide: _ ��3�'I' PCT 6fV105 if 1` Dater <br /> Ii PL rt 1 t) T r , ^% r—� <br /> R DEPARTMENT USE ONLY . <br /> Application Accepted by Date ,/� ��f 'Ana <br /> Pit o.Grout Inspection by Data Final Inspection by Date <br /> Additional Comments: – <br /> ❑ Stk 466-6781 ❑ Lodi 369.3621 0 Manteca 823-7104 .❑ Tracy 8354M <br /> Applicant - Return all copies to: Environmental Health Permit/Services 16D7 E. Hazelton Ave., P.O. Box 2009,Stk., CA 96201 <br /> �I FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT- <br /> INFO <br /> Eft 11!!tREv.,i si 1A <br />