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r �r <br /> ;. APPLICATION FOR PERMIT <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT '* <br /> w <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 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. <br /> Job Address City R_;EAG-IF'cv"c— Lot Size PM <br /> Owner's Name Marlowe iroverties. Address Phone 415 457 2351 <br /> 4 <br /> Contractor Datem,E n1oratiott—Address License No. L�RnRn� Phane(I t <br /> TYPE OF WELL/PUMP:"`�P NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK �/A _ SEWER LINES DISPOSAL FLD._NA PROP. LINE 1-(), <br /> FOUNDATION r AGRICULTURE WELL` 4 A OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 8 Dia. of Well Casing Zrr <br /> ❑ Domestic/Private I1 Gravel Pack ❑ Tracy Type of Casing P[1l, , Specifications .020 <br /> _ F] Public ❑ Other ❑ Delta Depth of Grout Seal 25' Type of GroutCemertt bento. <br /> I I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by. Datum Exploration <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well De truction ❑ Well Diameter Sealing Material itop 501 <br /> Depth Filler Material {Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f.1 REPAIR/ADDITION LI DESTRUCTION I 1 iNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property.Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS f I Depth Size Number <br /> SUMPS L Distance to nearest: Well Foundation Property Line <br /> 'DISPOS'AL PONDS ❑- <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 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 person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I 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." <br /> The applicant must CAII foivall required inspections. mptete drawing onreverse side. t� <br /> Signed X Title: l e— !� Date: / t <br /> nr <br /> FOR DEPARTMENT USE ONLY <br /> y Date T f&k Area <br /> Application Accepted byCd <br /> Pit orroti Inspection by Date Final Inspection by Date- o <br /> Additional Comments: <br /> 0 Stk 466-6781 El 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 /> FEE AMOUNT DUE AMOUNT REMITTEDK H RECEIVED BY DATE PERMIT'NO. <br /> �\ INFO <br /> +.EH 13.24IREV.iiasl \ <br /> 3 13 3-� -7- 7- P� l(PP/ <br /> EH 14.28 <br />