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. � t <br /> . ! APPLICATION FOR PERMIT <br /> 1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> CA <br /> , <br /> 1601 E. HAZETON.ACI,E+ STOCKTON, <br /> Telephohe (209} 466-6781 <br /> IPERMIT EXPIRES VYEAR FROM DATE ISSUED <br /> I (Complete in Triplicate) <br /> quin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> Application is hereby made to the San Joa <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. I�rr <br /> ' 1n, ' Cit of Size PM f <br /> Job Address <br /> ails i Phone <br /> Owner's Name �rr (X <br /> 6 �!l' <br /> Contractor <br /> Address 1_�a JC Z� License No. 7 Phone <br /> TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT F-1DESTRUCTION ❑ ` <br /> PUMP INSTALLATION El SYSTEM REPAIR OTHER 1-1 <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS. _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 <br /> Dia. of Well Casing ! <br /> C] Industrial ❑ Open Bottom <br /> E1 Manteca Dia. of Weil Excavation , <br /> C /Uamestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Type of Grout <br /> F) Public fl Other Fl Delta Depth of Grout Seal yp _ <br /> I I Irrigation _-Approx. Depth l is tern Surface Seal Installed by r f <br /> k--.,Type <br /> 5 LA_ H.P. State Work Done <br /> k 3 <br /> Repair Work Done - Type of Pump <br /> Well Destruction ❑ Well Diameter Sealing Material_ltop-50.1------ — ;. <br /> Depth <br /> I. Filler Material'm6ldw,50`-Ir t ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION Ll-� DESTRU;�IO�aNailabpelw thin 200 feet.) if public 5ewve�is <br /> I <br /> j <br /> Installation will serve: Residence� Commercial— Other <br /> l \ <br /> Number of living units: Number of bedrooms � �- -- �"'""""""� � +' <br /> 111 ` Water table depth <br /> Character of soil to a depth of 3 feet: t �- <br /> ity No-Compartments r <br /> SEPTIC TANK ❑ Type/Mfg 1 Capacity—/NO- <br /> PKG. TREATMENT PLT. ❑ 1Netliod of Disposal t i <br /> i <br /> Distance to nearest: Well . I Foundation aZroperty'Line{ r <br /> LEACHING LINE ❑ No. & Length of lines `Total lengthisize <br /> FILTER BED ❑ Distancekto nearest: Well 1 Foundation Property Line I <br /> V <br /> I j , i 4,t �-i 1 <br /> i <br /> SEEPAGE PITS 4 I Depth size Number <br /> I f Property Line <br /> SUMPS ❑ Distance to nearest: Well � Foundation P Y <br /> If DISPOSAL PONDS ❑ ' - <br /> r I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stat laws, and <br /> kk�.�rules and regulations of the San Joaquin Local Health District. <br /> r Home owner or licensed agent'°s signature certifies the following.—I-certify that-in,-thu-performance-of-the work-for-which-this"pAr?fiit-is issued'I-shall-not-' <br /> employ any psuc nn as to become subject to workman's compensation laws bf California.",Contractor's hiring or sub-contracting signature <br /> certifies <br /> 61a=wing: I cert y that inthe rforman of the work for_whichY^this,permittisissued, I shall er iploy persons subject to workman's compensa <br /> tion lawr ia." <br /> The apps call 11 requi . C pl Farrrrsy vn r s amide• d <br /> Signed <br /> Title: Dale: <br /> R DEPARTMENT USE ONLY r <br /> r q <br /> i <br /> Date <br /> Area. <br /> Application Accepted by r <br /> Data Final Inspection by Date <br /> Pit or Grout Inspection by yw <br /> Additional Comments: ;.� <br /> 835-6385 <br /> ❑ Stk 466-6781 C) Lodi 369-3621 C] Manteca 823-7104 ❑ Tracy <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> F+ <br /> { FEECK RECEIVED 8Y DATE PERMIT NO. <br /> gA UNT DUE AMOUNT REMITTED CASHINFO♦ EH 13-241REV.i/H 5) 5/a� <br /> EH 14-26 <br />