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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> .� -. (Complete in Triplicate).: . .�'.t0.- <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct arld!or instate the work herein described. This application is <br /> made in compliance with Sar-Joaquin County Ordinance No.549 for sewage or No, 18b2 for y,,ell pump and the flutes and Regulations of the San Joaquin <br /> Local Health District. <br /> �.�5/ .5, -,� _ .city-7 � �. Lot size� PM <br /> Job Address <br /> 7 A- - <br /> [/-7 � �c� <br /> Owner's Name r ��- i Address �� L G✓�c v --- Phonle <br /> � Z�< L terse No._ c Phcln+3 <br /> Convactor s Name^ C `�"'4"� _ <br /> TYPE OF WELL;PUMP:i `ti T NEW WELL ❑ WELL REPLACEMENT _ DESTRUCTION.Ll <br /> PUMP INSTALLATION I SYSTEM REPAIR G OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTSC TANK 0 SEWER LINES - - - DISPOSAL FLO._ PROP, LINE _-... <br /> „i FOUNDATION - r t AGRICULTURE WELL _ OTHtR WELI PITS/SUMPS _ <br /> INTENDED USE --!6-TYPE OF WEL_t PR09LEMARE_A CONSTRUCTION SPECIFICATIONS r <br /> L1 Indus7ial ❑ Open Bottom ' ❑ Manteca Dia. of We1­Excavation — Dia. of Well Casing <br /> 1 ❑ Tracy Type of Casing v t�l� Specifications <br /> ❑ DorneVictPrivate ❑ Gravel Pack g- <br /> r 17 Public Other C Delta Depth of Grout Seel '-� Type of Grout r� <br /> 1-1 Irrigamri �—Approxi Depth 7 Eastern Surface Seal Installed by t �1 <br /> Ropai-Work Done C Type of Pump ' — H.P- �' State Work Done <br /> Sealing Material Wl ' 1 — <br /> Well Destruction I- Well Diameter — g P 1 <br /> ' Depth Filler Material (Below 50') —_ l V-1 <br /> TYPF OF SEPTIC WORK:, NEW INSTALLATION G REPAIRiADDiTION ❑ DESTRUC-ION ❑ IND sept•c system permitted if pubic sewer rs <br /> r available within 200 feet.) <br /> Installation will serve: .Residence [r Commercial_ Other <br /> Number of Wirtg units:I _ Number of bedrooms l ll <br /> Character of soil to a depth of 3 feet:_ Water table depth �. <br /> SEPTIC TANK I Type:Mfg r ��y .—. --. L - Cawcityy;2.de No. Compartments <br /> PKG. TREATMENT PLT. L' Method Of Disposal *J <br /> Ll Distance to,nearest: Welt 1610 -- Foundation_-%� Property Line 162/ 1 4 <br /> LEACHING LINE I I No. 8 Length of lines _ _ Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation— Property Line <br /> SEEPAGE PITS L- Depth <br /> SUMPS , Distance to nearest: Well_ Foundation_._—_ Property Line <br /> DISPOSAL PODS L • r <br /> i hereby certify that I have prepares this ion and dhs-work vrdl be done In ac idance with Sa Joaquin county ordinances,state laws, and <br /> ,Liles and raguLations of tha_San Joaquin Local'Health District. <br /> Home owner or licensed agent's signature dfrtifles 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 subiect to workman's comptinsation laws of California." Contractor's hiring or sub contracting signature <br /> r enifies the following:"I certify t in the p6rformanae(j.1 the work fcr which this perrnrt is sued, I shall employ persons subjaet o workman's t5cmpen4rt <br /> thin laws of Calflor rili1. -1 ! '^� <br /> r <br /> The appiirAnt st Coll, r all quire® pe a drawing,] on reverse side. <br /> Date: <br /> Signed X. ld - Title' <br /> FOR DEPARTMENT USE ONLY j <br /> Application Accented by T Date 1 Area <br /> 1 Pit or Grout Inspection by / {Date � Final irxvpactlon by Date <br /> Additionat Comments: <br /> L I Stk 4AB-6781 C Lodi 369-3821 C Mantaca Bx3-7104 ❑Tracy 835-6395 G <br /> Applicant • Retum all copies to: Environmental fiaelth Permit/Services 1601 E. Haze+tan Ave., P.R. Box 2009• Stk., CA 95201 <br /> FEE A.MOUrYf bUE AMC}UNT REMITTED cK H RECEIVED BY DATE " PERMIT NO. <br /> INFO <br /> �^ � <br /> . '] Q4_,G <br /> 1G <br /> EN 1121 iREv 1083; "1 ] <br /> !H 1425 �1 <br /> - <br />