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%_Z-4 - - <br /> `' APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA y <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 forapermit to construct and/or install the work herein described. This application id <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> 927. <br /> Job Address Y City 8t0CktOil Lot Sizei <br /> f t PMS <br /> Owner's Name ,1W.1, ,. Address <br /> .7,4295 747 S B-mt,;d ;�v Phone 40� <br /> Contractor Address <br /> TYPE OF WELL/PUMP; License No. Phone <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUC�E[] <br /> 1'� O i,e f 13 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 30 ft SEWER LINES OTv` <br /> FOUNDATION Q -� DISPOSAL FLD. PROP. LINE . 5 . > <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca <br /> Dia. of Well Excavation -,^;- 1:t•-Dia, of Well Casing <br /> ❑ Domestic/Private ❑ Grave! Pack El Tracy <br /> T� <br /> EJ Public El Other ❑ Delta Specifications <br /> Depth of Grout Seal Type of Grout <br /> ❑ Irrigation _. Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H P I <br /> Well Destruction State Work Done <br /> l Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 n)1. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTrVIN '{No septic system permitted if public sewer is hJ <br /> Installation will serve: Residence. x Mailable within 200 feet.) ' <br /> _ Commercial Other <br /> Number of livink uhits: 1 '` <br /> g Number of bedrooms 2 <br /> Character of soil to a depth of 3 feet: n'- ' F 4 <br /> SEPTIC TANK ❑ Type/Mfg Water table depth 0 I t. W <br /> PKG, TREATMENT PLT. ❑ Capacity No. Compartments <br /> Method of Disposal <br /> Distance to nearest: Well Foundation M <br /> —4f 4f_ Property Linej$.�_ 1 <br /> s. <br /> LEACHING LINE ❑ No. & Length of lines done <br /> FILTER BEDTotal length/sizer <br /> ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS ❑ Depth Size 1 <br /> SUMPS Number <br /> ❑ Distance to nearest: Well Foundation ----- <br /> Property Line <br /> DISPOSAL PONDS El <br /> 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 st ca for a requir ins tions. Com late drawing on reverse side. <br /> Signed <br /> ' Title: 0,,vn( Date:T-7 Le.-I TJ <br /> i ry FOR DEPARTME - USE ONLY Q <br /> Application Accepted by i�1/ Date " — J + <br /> Pit or Grout Inspection by Date <br /> final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <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 <br /> INFO AMOUNT REMITTEDDATE CASH RECEIVED BY PI RMIT'NO. <br /> i EH 13-24(REV.5/8 s7 ?o �. <br /> EH 1428 AV— ~ a , J gs r 'v.:sAP <br />