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1 <br /> APPLICATION FOR PERMIT <br /> ., SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <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. r' <br /> Jab Address a z� City -Z 7 <br /> sT Lot Size �' PM <br /> Owner's Name 7—�1 101r,17'41 S$ Phone <br /> Contractor <br /> /Z07_0 Address P-®` �3 ��'� License No. S` S 3�f Phone <br /> T OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 <br /> � q PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> Y DISTANCE TO NEAREST—SEPTIC TANK SEINER LINES DISPOSAL FLD. PROP. LINE <br /> is/tir FOUNDA AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> . u i <br /> INTENDED USE TYPE OF WELL PR REA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial` r'� 11 Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing I <br /> ElDomestichPri�te ❑ Gravel Pack ❑ Tracy Type of a Specifications <br /> Ll Public ❑ Other ElDelta i Depth of Grout Seal I Type of Grout <br /> ❑ Irrigation �Approx�epih —�Easfern ES ealJnstalledy. <br /> Repair Work Done El of Pump �' H.P 1,State Work Dione I <br /> INell,Destruction ❑ Wall{Diameter 6 Sealing Ma p' <br /> (top 50'1 <br /> 9ler_Matersatl,IB�low. - <br /> TYPE OF SEPTIC WORK: NEW INSTAL`LATI'ON REPAIR/A DITIbN ❑ DESTRUCTION ❑ (Nb septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serves, Residence Commercial X Other i <br /> Number of living units: I� NUmbef o drooms ` <br /> Character of soil to a depth of 3 feet:' t Water table depth <br /> SEPTIC TANK )W T�jpe/Mfg � � C�p'`iCRe ', apace yi 6OO09lf No. Compartments <br /> PKG. TREATMENT PLT. ❑ �. Method of Disposal ��1_T0r A& <br /> Distance to,nearest: Well 244 f Foun lord Property-Line <br /> LEACHING LINE ElNo. & Length of linesi �' m Total length/size <br /> FILTER BED `�j Distance to neares�I\Well i oat\ Foundation CJ Property Line . F` <br /> SEEPAGE PITS ❑ Depth SizeI i I ? � i umder <br /> ii ' <br /> SUMPS ❑ Distance to nearest: <br /> Well <br /> + Fou d�\L atit { <br /> on € Property Line <br /> DISPOSAL PONDS ❑ i �, 4 i <br /> I hereby certify that I have prepared this application and that the woik will be;done ima,ccordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. I i l , <br /> Home owner or licensed agent's signature certifies the following: "I certify h ` in the per o"rice 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 complsatign laws of;41ifornia."Contractor's hiring or sub-contracting signature <br /> certifies the following: "1 certify that in the performance of the work for which this permit is issued,4 shall employ persons subject to workman's compensa- <br /> tion laws of California." ll\ ? <br /> The applicant must c Or all requir d inspec i s. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> Date: ` 7 <br /> FOR DEPARTMENT USE ONLYI \ <br /> Application Accepted Date Are l <br /> Pit or Grout Inspecti y Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-Ml ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83540% , <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> S <br /> + EH 13.24(REV.7/65) .•� {'L _ {3r�-7 71�716 <br /> EH 14-28 <br />