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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL;HEALTH DISTRICT <br />1601 E. HAZEL T ON AVE.,.STOCKTON, CA <br />r Telephone (209) 466-6781 <br />PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br />s.. (Complete .in.Triplicate) <br />Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein decr bed. This application ismadeincompliancewithSanJoaquinCountyOrdinanceNo.549 for sewage or No. 1862 far well/pump and the Rules and Regulations of the San JoaquinLocalHealthDistrict. <br />Job Address ti',h ,, <br />r <br />s ;..' "I, rA t, ~ l <br />City r'C 9 Lot Size <br />6 G <br />PM <br />Owner's Name NA —"Address -- <br />Phone <br />T." rContractor_._ , , G Gc;2 <br />Address <br />17>oa y7 ' <br />TYPE OF WELL/PUMP:License No r2—,S-ka Phone_NEW WELL WELL REPLACEMENT DESTRUCTION y, <br />i <br />UMP-INSTALLATION-0--,.e,,.-SYSTEM-REPAIR--P—_ U <br />DISTANCE TO NEAREST: SEPTIC TANK OTiifR`lp <br />SEWER LINES' DISPOSAL FLD. PROP. LiNEFOUNDATIONAGRICULTUREWELLOTHERWELLPITS/SUMPSINTENDEDUSE _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSIndustrial1POpenBottom Manteca Dia._of Wel! Excavation Dia. of Well CasingDomestic/Private p Gravel Pack Trac ° g <br />r y " Type-bf Casin tElPublicQOther ' ' <br />g <br />t Specifications <br />Delta Depth of Grout Sea!13Irrigation Approx. Depth Eastern <br />Type of Grout <br />Surface.Seal Installed by ARepairWorkDone " Type of Pump H P <br />Well Destruction Whell Diameters State Work bone_ <br />Seating Material"(top 50') <br />1Depths <br />Filler Material (Below 50')TYPE OF SEPTIC WORK: .NEW INSTALLATION REPAIR/ADDITION DESTRUCTION fNo septic system permitt;ifpub;1icsewer is <br />fi <br />4 <br />rt <br />available within 200 feet.}Installation will' rve: Residence_CorArcial Other <br />r <br />Number of living units: Number of bedrooms <br />Character of soil to a depih of 3 feet: <br />SEPTIC TANK„ 8i Type/Mf <br />1111 D Water table depthjType/Mfg ter'Capacityo-D No. Compartments iPKG. TREATMENT PLT. b 1 iT17-of Disposal 3.Distance to nearest: i Well ( --_ Fipundation Property Line i <br />LEACHING LINEl <br />tNo. & Length of lines Total length/size l Fr fFiLTERBEDDistancetonearest: W I d.. X P r4 - _ Fourldatioii""- --,-- Property Lisle <br />111 <br />SEEPAGE PITS - Depth Size `* <br />r' <br />2 <br />SUMPS Nu'rlmber <br />Distance to nearest:- Well 1S^O' Foundation cSDISPOSALPONDS v' <br />dJ <br />Property Line SFS <br />Si i,_ <br />hereby certify that I have prepared this application and that the work wiA-be-dgr Q ><.accordance w6'San Joaquin county ordinances, state laws, andrulesandregulationsoftheSanJoaquinLocalHealthDistrict.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 notemployanypersoninsuchmannerastohecomesubjecttoworkman"s compensation laws of Califor4ia." Contractor's hiring or sub-contracting signature <br />icertifiesthefollowing: "I certify that in the performance of the work fors hich this permit is issued,Ishall employ persons subject to workman's compensa-tion laws of California." I h <br />The applicant must call for r <br />required inspections. Complete drawing n rev r side. <br />f <br />Signed A <br />Title:.i.. i-, , <br />Date: L= <br />FOR D P RTIU N USE ONLY 1 <br />Application Accepted by $ <br />Datey Areay <br />Pit or Grout Inspection by Date 'F. al Inspection by 4 Date <br />Additional Comments: s <br />Q 5tk 466-6781i-'Lodi 369-3621 Manieca 823-7104 Tracy 835-6385,Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O; Box 2009, Silt., CA 95201 <br />r <br />F <br />EEE , AMOUNT DUE.:a -A T EINITT D--.. CK.INFO <br />C,4SH "vRECEIVED 6Y: -DA-TE <br />EH 13-24(REV. <br />EH 14-26