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AYM�'�D - <br /> _ APPLICATION FOR PERMIT R [,ElV <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 ' ' {AV1Ra <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 Roles and Regulations of the San Joaquin <br /> Local Health District. -P, <br /> Job AddressLCQZy�, <br /> City/r L Lot Size ' QPM <br /> Owner's Name 4LG9 - ._ Address Phone l( <br /> I - - <br /> Contractor_Aw Address 7 4-�6&c o-�_icense No. �r Q Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER f� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 3► <br /> JY,, <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack C1 Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other rr ' ❑-'pelta' DepthlLf Grout Sea! Type of Grout <br /> �._i .-__P. -fid__ _ _. <br /> ❑ Irrigation =Approx. De th❑ Ea`sfern—Surface Sea! installed by + <br /> Repair Work Done Type of Pump s -H,P-•�?,� State Work Done <br /> Well Destruction ❑ Well Diameter '�3'` Sealing Materialy(top 501 <br /> Depth + Filler.MaWrial {Below 501 6 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION fO sDESTUCTION ❑ ( o septic system permitted if public sewer is <br /> i t� available within 200 feet.) <br /> Installation will serve: Residence Commercial�.•.tther ti ' <br /> Number of living units: Number of bedrooms 7 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Te/Mf .._ . ;.., ,�.aj ' <br /> Type/Mf <br /> 9 Capa'fity No. Compartments <br /> PKG. TREATMENT PLT. ❑ € _/ � Method of Dis osal <br /> Distance to nearest: Well ! p <br /> Foundation Property Line p <br /> t` <br /> LEACHING LINE ❑ No. & Length of lines +F Total length/size <br /> FILTER BED ❑ Distance to}nearest: Well <br /> Foundation Property Line r <br /> �j <br /> SEEPAGE PITS ❑ Depth j Size A Number <br /> SUMPS ❑ Distance to nearest; WellFoundation Property Line <br /> DISPOSAL 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 <br /> " fy 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:"1 certify that in the performance of the work for whichjthis permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call f I required inspections. Complete drawing on r rse side. <br /> Signed . ��—�( <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY , <br /> Application Accepted by Date t 'Area ' <br /> i <br /> Pit or Grout Inspection by Date Final Inspection by Date �Y <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 <br /> Applicant- Return all copies to: Environmental Health'Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> t ' <br /> FEE. AMOUNT DUE j AMOUNT REMITTED CK# <br /> INFO CASH RECEIVED BY, DATE PERMIT NO. <br /> + EH14-2B3-24 IREV.t/a51 �`r, __. � <br /> EH I <br />