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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON OIC AVE., STOCKTON, CA <br /> 9 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 fora 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. ;3 i <br /> r 3 - <br /> Jab AddressCy?rfs' City _Sh=- %CVJ __ Lot Size 20 CiOV-94 - PM <br /> r <br /> Owner's Name 'k” !/on 1eJ1L Address r PePhone <br /> 'r u i� <br /> _Contractor—d <br /> _- am <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 0 , DESTRUCTION.❑, <br /> n t PUMP INSTALLATION ❑ SYSTEM-REPAIR ❑7 <br /> -- ----g-- - - <br /> '.---D ISTANCE 70 AREST: SEPTIC TANK $SWI=F*-LINES"'--� ��"t""-"DISPOSXtt ftD:� �-PflOP-L-INE—� --i-� •---"'-"`""'� <br /> ! FOUNDATIONAGRICULTURE WELL ;OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL" PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ��<r <br /> ❑ IndustrialI a<pen Bottom ❑ Manteca Dia: of WOVExcavation Dia. of Well Casing + <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing s T-*e L Specifications p } <br /> * Public F1Other F1 Delta Depth of Grout Seal , Type of Grout &S:.at <br /> N/f IrrigationApprox. Depth I I Eastern Surface Seal Installed by _ <br /> Repair�Work Done ❑ Type of Pump TuRlS,n H.P. 2. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 \ <br /> i Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted it public sewer is <br /> I } available within 200 feet.) <br /> �.� Installation will Residence Commercial____ Other F <br /> Number "living units: Number of bedrooms b, <br /> 3 <br /> Character of soihto.a'dept6,)of 3 fe Water tabl <br /> SEPTIC TANK ❑' Type/Mfg Capacity ompartments <br /> � <br /> PKG. TREATMENT"PLT. ❑�' Method of Disposal <br /> Distance to nearest: Well Found Property Line <br /> LEACHING LINE "� ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to ne Well Foundation <br /> Property Line ! <br /> i } <br /> SEEPAGE PITS Depth'1 Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISP05 L 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 regulations of the San Joaquin Local Health Di§trict. <br /> Homeowner 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." I <br /> The applicant must call for all require inspections. Complete drawing on reverse side, p� <br /> Signed <br /> XTitle: GQ Date: .13 <br /> i <br /> DEPARTMENT USE ONLY f <br /> � - q # <br /> Application Accepted by <br /> `- Date 3`�" _ L 6 Area t <br /> Pit or Grout Inspection by ` Dat Final Inspection by Date <br /> j 1 <br /> a Additional Comments: �- <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 D Manteca 623-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> a <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE �PERMIT'NO. <br /> INFOCASl1 <br /> * EN 13-24 EH14-28IREV.tin5F /� ` v /� C F � <br /> I <br /> F•- i <br />