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APPLICATION FOR PERMIT <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 /> (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Heaith District. / ,( <br /> Job Address City nr'K• Lot Size PM <br /> Owner's Name Vf'i .4 ��/C Address Phone <br /> Lfl,Me ` Q <br /> Contractor �Q /uS Address E�/ �Zjg Cd.1" �License No. �� Phone ` <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION QAfp.(JrW,55k YSTEM REPAIR 5iL OTHER ❑ <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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> X�Ibomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications { n <br /> El Public ❑ Other El Delta Depth of Grout Seal Type of Grout V t <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done oftA .hEl-�,7-M57 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 :{>R <br /> Depth Filler Material (Below 501 V'11 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms / <br /> Character of soil to a depth of 3 feet: Water Mable depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well __ Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to-nearest:-­ Well Foundation Property;Line <br /> SEEPAGE PITS ❑ Depth L _Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ; <br /> I hereby certify that I have prepared this a¢plication and that4e 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."Contractors 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." i %^ <br /> The applicant require ctions. Comilefe drawin on re arseAide. <br /> f <br /> ,Kr <br /> SignedMIX <br /> Ttle:�t Zze;ee Date: <br /> !" T USE ONLY X <br /> Application Accepted by Date 1_1 <br /> 0 <br /> J..J�7J"7 Area �— v <br /> lllt 9 <br /> Pit or Grout Inspection by Date + �Final Inspection by o-� Date <br /> s <br /> "Additional-Comments: <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83545385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 55201 <br /> FEE MOUNT DUE AMOUNT REMITTED• Cx RECEIVED BY DATE LPERMIT"NO.INFqCASHyEH 13-244REV.1/s 5) 0 �.k, Jf <br /> EH 14-28 f <br /> /� <br />