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APPLICATION FOR PERMIT u <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466.6781 <br /> PERMIT EXPIRES 1 YEAR FROM_DATE_ISSUED <br /> _ 41i <br /> (Complete in Triplicate) t•� <br /> rr,.. <br /> hereby made to the San Joaquin Local Health District for a Permit to cnnstruct and/or install the work herein described.This application is <br /> p,mphanco with San Juaq,nn Cuunly Ordutenee No.149 for sewage or No. Ilii)•!for well/pump and ilio Rules and Regulations of It San J <br /> oaquin <br /> 1,ra: licalft+ Dislnct. / "t•; <br /> c" rI ( //_ n y ,�=-'_� Lot Size ' PM <br /> Address �l�l.�--�J._�--•L'��1�-�-�-�" cit <br /> 114 1 <br /> wner's Nam <br /> o _ udr�ss i <br /> f.onitaclor /t1J-- _— _—Address License No. Phone <br /> fYrc Of WELL/PUMP NEW WELL I. WELL REPLACEMENT 1 I DESTRUCTION 1.1 `r <br /> PUMP INSTALLATION U SYSTEM REPAIR U OTHER O <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 /> Industrial CI Open Bottom C1 Manteca Dia. of Well Excavation Dia.of Well Casing <br /> Domestic/Privole D Gravel Pack D Tracy Type of Casing_ Spaeilieatlons <br /> � I vbhc <br /> I l Other 1-1 Delta Uepth of Grout Seal Type of Grout - i 1 <br /> i titillation __ Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump _ H.P. State Work Done <br /> Well Destruction D Welt ^Iameter Sealing Material Itop 501 <br /> r•. <br /> Depth Filler Material IBelow 501 — <br /> 11'I`f. OF SEPTIC WORK: NEW INSTALLATIO I REPAIR/ADDITION I I DLSIRUCTION 1 I INoi ie s lic syslarn lmilled if pubbi:sawer is •, <br /> within 200 fee111 <br /> Installation will serve: Residence Commercial— Other [Sx <br /> Number of living units: 4s Number of bedrooms. _ FY <br /> Character of soil to a depth of 3 feet: dia &I Water table depth f' <br /> r <br /> SEPTIC TANK fT'�Fype/Mfg Capatity� No.Compartments !ls <br /> rt, <br /> PKG. TREATMENT PLT.Ll Method of Disposal� i <br /> Distance to nearest: Well _ Foundation 3Q Property Lina <br /> LEACHING LINE &—No. A Length of lines —'J!J u Total length/site <br /> FILTER BED 1_1 Distance to nearest: Wei Foundation Property Lka <br /> SEEPAGE PITS Fel-Depth _"S --Site�jp — Number �+ <br /> SUMPS l I Distance to nearest: Well Foundation Property Lkie <br /> DISPOS4L PONDS Il 1y <br /> I hetet,y candy that I have prepared this applicatlon and thar-AU work will be iltxw ki accordance with Sari Joaquin county ordwwxes,state laws,and <br /> rules and reputations of the San Joaquin Local Health Dr'itriet. i <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which"permit is issued.I shall not <br /> employ any person M such manner as to become subject to workman's compensation laws of California.''Contractors hirkip a Lob-contractirig aigruture <br /> certifies the loll :"I unity that in the performance of the work for which this parmii Is fausd,I tlfiai employ persons subject to workman's convenes <br /> lion laws ofCalifornia.'* <br /> The applicant Test can for all required inspectio4s. Complete drawing on reverse side. <br /> Signed YJL / ' .,;.Title: �. Date: <br /> FOR DEPARTMENT USG-ONLY <br /> Application Accepted byY� 7�'� /�[[ 66 Det• <br /> Grout Inspection by Date�'r'T�""'—/Final Inspe <br /> is ction by y44 1'(6 <br /> Date; ' <br /> Additional Comments: <br /> U Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823.7104 O Tracy 835.6385 <br /> Applicant- R•tum an copies to: Environmental Health Parmit/Services 1861 E. Hazelton Ave., P.O. Box 2009, Stk.,CA 95201 l <br /> J <br /> FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED OY DATE <br /> CASH PERMIT NO. <br /> INFO - 3' <br /> [N 17:�INN.Lill sitI^y <br /> .Y <br />