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r 3A. <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 3 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . <br /> (Complete in Triplicate) <br /> Application ' <br /> iI{aquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in co ounty Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health Di <br /> Job Address �2 <br /> City � Lot Site _ PN! ... <br /> _ 3 <br /> Owner's Name esu / .^''-^ Phone! rG 5'-XP <br /> Contractor's Name ��'� "�'r License No. � <br /> ....�.�. Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ) DESTRUCTION <br /> PUMP INSTALLATION Q° SYSTEM' .REPAi'R u s OTHER 0 <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES . DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGfiICULTURE WELL !t OTHER WELL-- PITS/SUMPS <br /> t, - <br /> INTENDED USE TYPE OF WELL <br /> indusirlat— :` Open Bottom Ir Manteca Dia. of Well Excavation•.. i Dia. of Well Casing W <br /> ,Y15omestic/Private ❑ Gravel Pack LJ Tracy Type of Casing.._� Specifications <br /> .� Public C Other C Delta Depth of Grout Seal IType of Grout <br /> Irrigation ---Approx. D�h C Eastern Surface Seal Installed by <br /> fiepair(Nook Done ? Type of Pump _ e H.P. I _ 'lata Work Done <br /> Well Destruction 1J Well Diameter _. Sealing Material(top 50') <br /> Depth Filler Material(Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t- REPAIR/ADDITION © DESTRUCTION0 (No septic system permitted if public sewer is <br /> available within 300 feet.) l <br /> Installation will serve: Residence—_ Commercial Other <br /> Number of living units: Number of bedroomxi _ <br /> �"� i •� <br /> Chara:ter of soil to a depth of 3 feet:_ 4 Water table depth <br /> SEPTIC TANK Li TYpe/Mfg __ Capacity— _ No. Compartments <br /> PKG. TREATMENT PLT, .--, Method of Disposal.. <br /> Distance to nearest: Well Foundation Property Line — <br /> LEACHING LINE rJ No. & Lon <br /> gtfl of lines: _ Total iargthJsiae"' <br /> FILTER BED s-L�. Datance.to.nearesi:�: Well=.` =' Foundation-t---=A--=_Pro"'party Line <br /> SEEPAGE PITS 0 Depth _ Sita � �� <br /> Number <br /> SUMPS 17 Distance to nearest: Well Foundation_. _ Property Line <br /> DISPOSAL PONDS 0 — <br /> I hereby certify that I have prepared this application and that the Work will be done in accordance with San Joaquin county ordinances,state laws, and <br /> rules anc regulations Of the San Joaquin Local Health Distric'es ' <br /> Honowner or licensed agent's signature certifies the following; "I certify that in the performance of the work for which this <br /> not <br /> employ any person in such manner as to become subiect to workman's compensation laws of California."Contractor's hiring orrwb•contit is i actrngl�lit <br /> ure <br /> caftIsm of of California."the following: " certify tffy that In the performance of the work for which <br /> tion lthis permit is issued,I shall employ persons subject to workman's oompensa- .� <br /> tion a <br /> The applicant i for all aired ins a��+!ons. Camplrttr drawing on reverse side. <br /> Signed X �� � /1.srL s. <br /> r �� _ Data: <br /> rpt Op DEPARTfN NT USE ONLY , ! <br /> Application Accepted by �' < Data —1 � <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by - s n Date .} <br /> Additional Comments: <br /> C Stk 468-$781 C' Lodi 389-3621 C Manteca 873-7104 C' Tracy 835-SM — r <br /> %pplicant- Return aN copies to: Environmental Health Perrtktt/Services 1801 E. Hazatton Ave., P.O. Box 2009,Stk., CA 952x1 <br /> EEE AMOUNT DUE AMOUNT REMITfiED K <br /> INFO CASH RECEIVED$Y BATE PERMIT•NNO. <br /> +til 1344Wv.10/m . <br /> EM 14-26 , n—Z> <br />