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T 1 <br /> APPLICATION FOR PERMIT <br /> J SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (203) 466-6781 <br /> PERMIT EXPIRES 1YEAR FROM DATE ISSUED A <br /> i (Complete in Triplicate) <br /> nstall the work herein describe .Tis <br /> Application is catior) is <br /> liheieby ance writhdSanoJoaqu nnCoumy Ordinance No.549 for sewage o No. 1B62 for wellapumto construct an /or 1p and the Rul s and R gulations of the San l Joaquin <br /> made in comp <br /> Local Health District-? <br /> City <br /> Lot Size O �' PM <br /> ,lob Address <br /> ,{ e `W &t-Phone a <br /> Dwner's Name Address%.}!�:„ -7 ) �` �j ?�? <br /> D( tv,6 ded <br /> nse No. 0 107 Phone_6 c7 ✓ <br /> Contractor t� J c-; Address <br /> LJ OTHER <br /> REPLACEMENT FF] <br /> OF WELL/PUMP: NEW WELL DESTRUCTION ❑ f <br /> t <br /> SYSTEM REPAIR El <br /> PUMP INSTALLATION ❑ OTHER ❑ i <br /> SEWER LINES DISPOSAL FLD. PROP: LINE <br /> (ISTANCE TO NEAREST: SEPTIC TANK �L <br /> FOUNDATION <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL Dia of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> I T e of Casing <br /> ❑ Domestic IPrivate ❑ Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout <br /> L f'1 Public � Cl Other i t 171 Delta <br /> I I Irrigation —Approx. Depth I ! Eastern Surface Seal Installed by <br /> .f H.P. <br /> State Work Done — <br /> Repair Work Done 11 Type of Pumpt <br />{ Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 <br /> Depth I Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I ! DESTRUCTION I 1 availableseptic <br /> withinsystem <br /> 200 feet.) if public sewer is <br /> Installation will serve: Residence `� Commercial Other <br /> ' Number of ed ooms 3 <br /> Number of living units: ___�-_ a Water table depth , <br /> Character of soil to a depth of 3 feet: (p No. Compartments '2 <br /> SEPTIC TANK lid Type/Mfg G 'Capacity <br /> bd-.- Method of Disposal <br /> PKG. TREATMENT PLT. ❑ ��,, t f - - � ---pro ert Line <br /> Distance to nearest: Well Fouhdat,on P, Yt -�� <br /> ii <br /> kk r `Total.uength/siz�t_- !A-d f = { <br /> h. LEACHING,LINE P"'No. & Length of lines f 2-., l Property Line <br /> FILTER BED - ❑ Distance to nearest: WeII )�Ur Foundatibo <br /> 1 <br /> s <br /> Well <br /> `( r Size 3 if 'Numb'e'r. I <br /> SEEPAGE PITS {� Depth " Lt <br /> c e Il)5 1 .._ Property Line � \ <br /> SUMPS ( -L�i Distance to nearest: � Foundation \ <br /> DISPOSALIPONDS ❑ <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 /> in the performance of the work for which this per <br /> Home owner or licensed agent's signature certifies the following: "I certify that mit is issued, I shalt not <br /> I 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 /> I tion laws of California." .I. <br /> drawing <br /> i The app lica t must cal fora required inspections. Complete rag o erse side. <br /> av <br /> t ! Date: ; <br /> Signed X Title: ; <br /> FOR DEPARTMENT USE ONLY { <br /> 1i <br /> Date � Area <br /> Application Accepted by APP <br /> Data Final Inspection ACU Date <br /> (1)r Grout Inspection by .J,ICH j + '�APPI j��' <br /> Additional Comments: _ 4�1�t)� •� <br /> ElStk 466-6781 L3 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 �� „ fir$" rEr <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., kr %� u � <br /> App R <br /> _ {�"�4.fisttiv 4�tNiTS <br /> t F <br /> CK RECEIVED BY DATE PERMIT'NO, <br /> EE <br /> AMOUNT DUE AMOUNT REMITTED A H <br /> INFO <br /> +.EH 1324(REV.t/Fl 5] 00 <br /> V <br /> EH 14-28 <br />