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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 4 4 <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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. ,. + <br /> Job Address (�u <br /> r City—," Lot Size PM <br /> If <br /> Owner's Name Address — Phone S'�S—q 12-7cp <br /> Contracto Lazt—Al.-C-1 Address p__dmz/jd•e4�r, q'a!yicense No?{�61 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 f <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> tkDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public D Other F1 Delta Depth of Grout Seal Type of Grout--.--- <br /> I <br /> rout__. _I I Irrigation —.-Approx. Depth, l I Eastern Surface Seal Installed by i <br /> Repair Work Done ❑ Type of Pump H.P 3/ State Work Don <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 111 REPAIR/ADDITION I I DESTRUCTION { I [No septic system permitted if public sewer is 01) <br /> Rte_ available within 200 feet.) <br /> Installation will serve: Residence _ Commercial�T Oilier <br /> Number of living units: Number of bedrooms f <br /> Character of soil to a depth of 3 feet: _— _ Water table depth'. �. <br /> SEPTIC TANK ❑ Type/Mfg Capacity +, 0No.ICompartments <br /> PKG. TREATMENT PLT. ❑ f Method of-Rosal r ; <br /> Distance to nearest: Well Foundation Cil"tPrpge y,Line <br /> =r, -tPLit ti <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <. <br /> 1 <br /> I <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI—Distance do nearest:­i�WeltFoundation=�P-roperty_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 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- <br /> tion laws of California." <br /> 1 <br /> The applicant must call for all req 'red inspections. Complete drawing on reverse side. <br /> Signed X _- Title: �iC-B�� Date: 11—to <br /> OR DEPARTMENT USE ONLY <br /> A/T <br /> Application Accepted by DateArea a <br /> Pit or Grout Inspection by ` Data Final Inspection by Date <br /> Additional Comments: 01, u r 4e s2o7 ea '{z ZGSL,24 old 1.1m) - <br /> ❑ Stk 466-6781 LTJ Lodi 369-3621 ❑ Manteca 923-7104 acy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 j <br /> r'� I <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED ` CASH RECEIVED BY DATE PERMIT'NO. <br /> +.£Ht3-28 <br /> 24iREV.i/x51 <br /> EH 14 <br />