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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA i <br /> - -Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t <br /> _ (Complete in Triplicate) t <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 Rules and Regulations of the San Joaquin <br /> ":'Local Health District. <br /> r <br /> Job Address CityLot Size PM <br /> `.Owner's Name —AA-49A .5' wal ''Address: 3l=4~� -moo/ss I <br /> <L ">. 3 a. - * Phone <br /> Contractor GLa .D G.+Oc1'A i4ddress O 1 t- AJJ AVE License No. 1-CY7L Phone & 3 v7/ [ <br /> TYPEi0F WELL/PUMP: +e'NEW�WELLf.❑---­€ 'WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> ! PUMP"INSTALLATION ❑ - SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ti s SE NER LINES, I DISPOSAL FLD: PROP. LINE <br /> i FOUNDATION'rf. '/AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL#""-PROBLEM AREAS CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom EI Manteca � Dia. of Well SExcavation Dia. of Well Casing � <br /> ElDomestic/Private ElGravel Pack ❑ Tracy -u} .Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Y Depth of Grout Seal '• Type of Grout <br /> EJ Irrigation jApprox.�Depth �'❑ Ea_st rn _ Surface teaiL.lnstalled by <br /> Repair'Work Done ❑ Type of Pump H.P. i w State Work Done <br /> Well Destruction [IW(iII'Diameter Sealirig'.Material {top 501) <br /> tT Depth j _ _ Filler Material IBe_14 501 _ <br /> TYPE OF SEPTIC WORK: ,NEW INSTALLATION I❑ REPAIR/ADDITION Wr DESTRUCTION El (No septic system permitted if public sewer is i <br /> I <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Y Other z <br /> Number of living units: Number of bedrooms ��tA j` Q <br /> Character of soil to a depth,of 3 feet:t: .�--�- Water table depth ® \ $ <br /> SEPTIC TANK ❑ Type/Mfg ��7��<�. Cape city No. Compartments <br /> PKG. TREATMENT PLT. ❑ J� <br /> JP1 Method of Disposal <br /> <: - <br /> < Distance to nearest: Well Foundation Property Line <br /> LEACHING 1-INE ❑ .No. & Length of s 1 Total length/size <br /> FILTER BED ❑ :Distance i serest: Well, Foundation Property Lina <br /> ��a� i � ♦sem - [ 4 --- ,. `.. ,.. t <br /> SEEPAG.E PITS bepth t' �»S�. _Size /A F .i } <br /> Number <br /> SUMPS '" ❑ nistance„to nearest:—Well- _Foundation 1 Property Line;,._ i <br /> DISPOSAL PONDS [] t <br /> I hereby certify'that I have prepared flNi application and that the work willbe done in accordance with San Joaquin county ordinances, state laws, and <br /> rules-and regulations of the Sari+Joaquin Local Health District. i 1 <br /> Home owner or licensed agent's sigriature certffies 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 fr w <br /> ohich this permit is issued,1 shall employ persons subject to workman's compensa- <br /> ..tion;laws of California." # ' <br /> Thesapplicant must call for fall required inspec. ns. Complete drawing on rqverse -side. <br /> Signed Title: - Date: <br /> FOR DEPARTMENT DISE ONLY, <br /> Application Accepted by ;' Date <br /> D"q <br /> Pit or Grout Inspection by Date 1_/ Final1l Inspection by Date <br /> Additional Comments: _ ; �. <br /> ❑ Stk 466-6781 ❑ Lodi 6369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63M <br /> Applicant- Return all copies to:,En'vironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> b � I <br /> FEE- <br /> INFO. AMOUNT DUE AMOUNT REMITTED CIC <br /> CASHRECEIVED 8Y DATE. PERMIT"NO. <br /> ", k <br /> EH 13-24(REV.t/a51 ��!C"..,y (4 ,,fir. <br /> EH W26 177, t /�/ r a�� <br /> �. <br /> r <br />