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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> 'Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t <br /> (Complete in Triplicate) r <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 /> f 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. <br /> Job Address �SBylo /V, lcJ �c t <br /> Lot Size = PM <br /> ` <br /> Owner's Name - _ Addre�sQs y7 _ Phone <br /> Contract or" Address . 11_dy -1,(, � License No o7c_G �p g QS <br /> Phone' - <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O <br /> PUMP INSTALLATION O �` <br /> �"� SYSTEM REPAIR O - OTHER (-1 J I <br /> DISTANCE TO NEARES IC TANK SEWER LINES _ _ DISPOSAL FLD. PROP. LINE <br /> FOUNDATI AGRICULTURE-WELL OTHER WELL { PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PRO REA CONSTRUCTION SPECIFICATIONS E <br /> J Industrial O Open Bottom ❑ Manteca ( ` <br /> f Well Excavation Dia. of Well Casing _ <br /> O Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casi Specifications C7 <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal <br /> Type of Grout <br /> ❑ Irrigation <br /> ---Approx. Depth 171 Eastern Surface Seal Installed by=_ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction L Well Diameter _ Sealing Mateiial (top 50'1 _ <br /> t... Depth Filler Material (Below 50') _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i REPAIR/ADDITION ❑ DESTRUCTION D (No septic system permitted if public sewer is <br /> I available within 200 feet:) r <br /> 1 a t <br /> Installation will serve: Residence_ Commercial-F_ Other <br /> ( <br /> Number of living units: <br /> rj Number of tedrooms / <br /> Character of soil tofa depth of 3-feet. <br /> -fet. CWater tabler <br /> 'depthSEPTIC TANK Type/Mf i -_ No. Compartmentsyg <br /> PKG. TREATMENT PLT. ❑ / <br /> i Method of Disposal <br /> Distance to nearest: } Well Foundation � Property Line <br /> LEACHING LINE io. & Length-of Iiiee s __ Total length/size v <br /> FILTER BED O Distance to nearest: WellFoundation Property Line " " `D <br /> „ - <br /> SEEPA'"GEAl�,S , DeP� Size -- <br /> t' SUMPS t Number_- I <br /> ❑ Distance to nearest: Well Foundation _ Property Line F <br /> DISPOSAL PONDS ❑ r <br /> I hereby certify that t have�trepared this application and that the work will be done in accordance with San Joaquin ns county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed-egent:s-sig penature-canifies-the following.- "I certify that in the pof the work for which thisp y <br /> rmit is issued, I shall not <br /> employ stay pe1sonYimiuch manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the-following:1;'1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." I , <br /> The applicant. ust call f II r uired inspections. Coenplete drawing on reverse slid t <br /> Signed�(1 ""+' l n Title: `l . . <br /> 'r r - " Date: _ <br /> f. FOR DEPARTMENT USE ONLY <br /> l li ,tom <br /> Application Accepted by 1 Date J r <br /> Area:-- <br /> Pit or Grout Inspection!by-1�----- - Date Final Inspection by <br /> Date 7lo d'6 <br /> Additional Comments: <br /> i7 —46x87$1 CT Lodi389 3621_ I�Manteca` 823-7104 'T❑ Tracy <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Silk., CA 95201 <br /> r FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO - RECEIVED BY <br /> /� �J CASH RECDATE PERMIT'NO. <br /> (. EH1324(REV.iinci 7Q 'UV �] �f }�f�., (� <br /> EH 14-28 /'r7'—`C �� /, <br />