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zE L �,��,, K APPLICATION FOR PERMIT <br /> 1 SAN JOAQUIN LOCAL HEALTH DISTRICT y <br /> f,�R�Ei✓ � J''� ��� � 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone{2091 466-6781 <br /> 1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> "�^-'-- (Complete in Triplicate) <br /> I,us <br /> permit to construct and/o <br /> r install the work herein described. This application is <br /> AP ication is hereby made to the San Joaquin Local Health District fora <br /> mad in compliance wit ' !o ui County Ordinance No. 549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. ?,;.` ' <br /> rl Cit Lot Size <br /> PM,-__.— <br /> Job Address <br /> Owner's Name @. LK p JOS _ <br /> 6 —?6 <br /> Address <br /> Contractor - <br /> TYPE t` EW WELL ❑ WELL REPLACEMENT ❑0-,, DESTRUCTION ❑ <br /> OF WELLIPUMP: <br /> POMP-INSTALLATION ❑ SYSTEM REPAiR"❑ _.=.� OTHER ❑ <br /> __. EW DISPOSAL FLD. PROP. LINE <br /> _ SEWER LINES <br /> DISTANCE TO NEAREST: SEPTIC TANK _ �- PITSISUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> a: .z <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIONS -IFICATIONS pia. of Well Casing <br /> ❑ <br /> Industrial ❑ Open,Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing "I�'6 <br /> ecifications <br /> k ❑ Domestic/Private ❑ Gravel-Pack ❑ Tracy Yp pe of Grouti7 Other ❑ DeltaDepth:of..GroutM Public "_" -�..Appyox. Depth 1.1 Eastern Surface Seal Installed by <br /> I 1 Irrigation St "*� <br /> Repair Work Done ❑ Type of Pump <br /> H.P. <br /> Well Destruction ❑ Well DiartieSeating Material (top 50'I, <br /> �ter _— <br /> Depth Filler Material (Below 50') t� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION I I alvailabptic system <br /> m permitted if public sewer is V ' <br /> Installation will serve: Residence:.!-- Commercial Other (� <br /> Number of living units: Number of bedrooms <br /> Water-table depth <br /> Character of soil to a depth of 3 feet: r <br /> Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg f' Method of Disposal <br /> f PKG. TREATMENT PLT. ❑ —1 ' <br /> TD`ra' Foundation~ PrLperty Line <br /> nceTto nearest:. Well <br /> .� - •• •-- •-• -. <br /> LEACHING LINE LI No. & Length`of lines Total length/size <br /> th/size <br /> Foundation <br /> f" Property Line / <br /> f FILTER BED ❑ Distance to nearest: Well unun <br /> - <br /> � SEEPAGE PITS l I Depth Size -Number <br /> r <br /> SUMPS Ll Distance to nearest: Well Foundation ` Property Line <br /> F - 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 signature <br /> owner or lig ag 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 pets in such ma er as to become su workman's <br /> compensation laws of,CalifI shall" Contractor's personslsub'ect to woring or rkman's sub-contracting <br /> certifies the fol wing: "I certif hat in th or nce the work for which this ermif is issued,!shall employ p 1 <br /> tion laws of alifornia." <br /> k The applica m s or 1l re io C �,edrawi"ng6 on si00, <br /> Signed X <br /> �e� <br /> Date: <br /> F DEPARTMENT USE ONLY — <br /> Date Area <br /> Application Accepted by <br /> Pit or Grout Inspection by Date Final Inspection by Date�el <br /> f Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 D Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 r <br /> t <br /> i FEE CK RECEIVED BY DATE PERMITHN <br /> OUNT l]UE AMOUNT REM CASH <br /> i INFO rEM <br /> k ♦.EH 13-24 IREV.1/n 51 '7�V`t- 6-11 -10 <br /> —1 �0- I <br /> F EH 14-26 <br />