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F <br /> I APPLICATION FOR PERMIT <br /> k <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i< 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone {209) 466-6781 <br /> F PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Joaquin 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 <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. <br /> F:I <br /> r Job Address 1 i' d A City Lot Size PM <br /> ~ 4� L ; `! Address 1 Phone `ZWO <br /> Owner's Name <br /> r �Po TO Address. �p� .3License No. <br /> Contractor X60 Phone <br /> TYPE OF WELL/PUMP: _ I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> I PUMP INSTALLATION ❑ SYSTEM REPAIR rQ �_ „}.,-OTHER ❑ �- <br /> DISTANCE TO NEAREST: SEPTIC TANK ,SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION, AGRICULTURE WELL_. OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF-,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .� <br /> L1 Industrial ❑ Open Bottom ❑ Manteca Dia.-of Well;Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type.of Casing Specifications <br /> 171 Public, (7Other F1Delta Depth of'Grout'Seal —Type of Grout <br /> .... :-k <br /> I I Irrigation _Approx. Depth 1.1 Eastern Surface $sal Installed by - .} <br /> f Repair Work Done ❑ Type of Pump f H.P, State Work Donk <br /> (Well fDestruction 0 Well Diameter Sealing'.Material (top 501 / "\ <br /> depth Filler Material fBelow 50') k <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR! DITIO OESTR�J N I I (No septic system permitted if public sewer is <br /> ..•: ? . 4 avallah y�wit�I �. etjJ�D ���pl <br /> A.�'7" i' lam"r� <br /> Installation will serve: Rest encs.� Commercial_____ Other <br /> Number of living units: Number of bedrooms % <br /> I Character of soil to a cl!ptho 3 feet: © a` i "' Water table depth ' <br /> SEPTIC TANK i Ie]' Type/Mfg ` A_" �apacity t'IVo. Compartments t <br /> PKG. TREATM'FNT PLT- L7' Method of Disposal <br /> Distance to nearest: Well - FoLndation w ' Property.Line { <br /> w <br /> Ile <br /> LEACHING LINE , No.& Length.6f lines '� ' Total length/size <br /> FILTER BED '❑ Distance to nearest: WeII ourrdation Property Line <br /> SEEPAGE PITS i I Depth + ' Size �t Number <br /> SUMPS ❑6 Distance-to nearest:- *Well '" Formdation r-��Property bine- <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared ihis/application and that the work will be 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 personh manner`as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the followinin certify that in the performance of the wor for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Califor a.' <br /> The applic t s II for all t ired i con et awing on II <br /> side <br /> 5igned.X - Title: . Date:.- �/ T <br /> f j FOR DEPARTMENT USE ON j <br /> Application Accepted by date Area p� <br /> `"``"Pit or Grouf'Inspection by' Date Final Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.' Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> E <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT-NO. <br /> INFO CASH <br /> *,EH t3- 0 <br /> 24{REV.1/n b l <br /> EH 14-2e <br /> { <br />