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8• <br /> • i <br /> - "' �y10 APPLICATION FOR PERMIT <br /> Q SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <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 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 sewag or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> a , <br /> Job Address 1 � City Lot Size PM . <br /> Owner's Name I�l•�,Y 11 I�ii i ]( 1' dr s Phone <br /> Contractor f J a cess " � � � ``!�"` License No.�PhR4^7 r <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ " SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES POSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WILL LEM AREA CONST CTION SPECIFICATIONS i <br /> ❑ Industrial El Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑:Tracy Typ !.Ling- Specifications r <br /> ❑ Public �� ❑ Other C1 Del 5 Depth of Grout a Type of Grout <br /> ❑ Irrigation --Approx. Depth Eastern Surface Seal Installed by i <br /> Repair Work Done ❑ Type of Pump H.f P. State Work Done <br /> Well Destruction ❑ Well Di eter Sealing Material [top 50') <br /> 1 Depth Filler Material-iBelow501- <br /> c <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION 1-1.(No septic system permit)ffff public sewer is �. <br /> f. •i'"7 `t I withi 200 flee ! <br /> Installation will serve: Residences Commercial_ Other <br /> Number of living units: Number of bedroom e <br /> Character of soil to a depth of 3 feet: �/'?ee 'r W er table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity � „„No. Compartments <br /> PKG, TREATMENT PLT- ❑ t 'Method-of_Disporal <br /> Distance to nearest: Well/� Foundationoperty Line� `•'d <br /> LEACHING LINE y No:& Length of lines z Total length/size <br /> FILTER BED. ❑ Distance to nearest', -well. foundation —rte-- =-7-Property Line <br /> SEEPAGE PITS ❑ Depth �r '. Siie Number I r l J , <br /> SUMPS Distance to nearest: Well f-t Foundation l Property Line ` <br /> DISPOSAL PONDS ❑ E <br /> I hereby certify that I^have prepared this application'a6d'that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules andtregulationskof the San Joaquin Local HealthDistrict—t 5 <br /> ,Home owner or.licensed agent's signature eertifies`the`foll6wing: "I certify that in the performance of the work for which this permit is issued, I shall not r <br /> employ any person in such manner as do 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., e <br /> + The applicant.mus all for all required insrpections. Complete drawing'on reverse side. k <br /> Ir 9f l <br /> Signed X i LP— # � A. Title: �,,, C l�i Date: �1 r <br /> } ; FOR DEPARTMENT USE ONLY <br /> `ApAlication Accepted by. ` l Date Area <br /> 10,i <br /> Pit or Grout Inspectio y Date Final Inspection by Date , <br /> Additional Comments: + I i��i�1. fv t i6'­'f1.111,- ,J- Ce.,4V e11��f/Cr,VtC �} ` <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ,(._,q;❑ Manteca'_ 7104 ' _-E],Tracy '835-M5 — <br /> App scant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 1 �rN <br /> )FEE <br /> NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. <br /> + EH 13-24 MEV.1 5) - C o �3 7-5-2- <br />; EH 14-26 } <br /> l L <br />