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f <br /> APPLICATION FOR PERMIT �. <br /> . .,:. <br /> ' SAN JOAQUINf LOCAL HEALTH DISTRICT - <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781- ' <br /> PERMIT EXPIRES 1 YEAR FROM'DATE ISSUED'" <br /> (C&f1 IeLe Irl TrlpllCBte) <br /> 11?1? S11t ! `-i , <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 Ryles and Regulations of the San Joaquin <br /> Local Health District: <br /> 1 <br /> Job Address 6i' - 1 AC Lot Size ��U 'PM <br /> Owner's Name C _ Address - c ` C Jpp IS MA� P— m Phone• <br /> Contractor <br /> - <br /> _&z,V e,R e-., 'e Address License No. � Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ 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_SPECIFICA_TION <br /> ❑ Industrial El Open Bottom ❑ Manteca `pia. of Well Excavation RDia. of Well Casing z� <br /> Domestic/Private ❑ Gravel Pack b4Tracy Type of Casing r A V- Specifications <br /> 0 Public ❑"Other ❑ Delta Depth of Grout Seal DO Type-of Grout' <br /> ❑ Irrigation —Approx. Depth ❑ Eastern Surfa a Seal Installed by l P <br /> Repair Work Done ❑ Type of Pump H. State Work Done <br /> .� <br /> Well Destruction ❑ Well Diameter `�� 5ealing aterial atop 50') e �. /!X L <br /> Depth A 0Filler Material [Below 50'1 <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 table 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 /> i <br /> LEACHING LINE ❑ No. & Length of fines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line " <br /> SEEPAGE PITS -❑ Depth Size r. Number" <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line ' <br /> DISPOSAL PONDS ❑ <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-regulatibns 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- l <br /> tion laws of California." ,* <br /> The n st call for all ]UZ, inspections. Completedrawing on reverse side. <br /> Signe Titl / e— e&4. Date: <br /> FOR DEPARTMENT USE ONLY i <br /> r <br /> Ap ication Accepted byr Date k' 4- <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection'hy pate <br /> Additional Comments: Y <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 &M'cFracy 835-6385 ' <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E."Hazelton Ave., P.O. Box 2009,-Stk., CA 95201 <br /> . --i <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO H-,. RECEIVEDZY r DATE. PERMlYNO. <br /> ` <br /> + EH13-24 TREY. 5 51 <br /> EH 14-28 <br />