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s APPLICATION.FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> -Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> .(Complete in Triplicate)',, j:.., <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 incompliance 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 :._ I)AV <br /> City _�, Lot Size s PM - <br /> F <br /> Owner's Name' Address S AA 4F Phone y'20! o <br /> Contractor i< 704 r. d��,S Address o l.2 6 T y 773 rS Phone y•Y7147" <br /> License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION 9- <br /> SYSTEM REPAIR ❑ OTHER ❑ j <br /> DISTANCE TO NEAREST: SEPTIC TANK %%ID SEWER LINES DISPOSAL FLD.J!M PROP. LINE -11 S <br /> FOUNDATION AGRICULTURE WELL 147`' OTHER WELL PITS/SUMPS <br /> � _ J <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCIpN SPECIFICATIONS i <br /> [IIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private X Gravel Pack 71 Tracy Type of Casing ✓�Il Specifications <br /> ❑ Public ❑ Other _ 11f]elfa "" Depth of Grout Seal 1 c']J Type of Grout C e <br /> ❑ Irrigation ---Approx. Depth ❑'Eastern Surface PSeal Installed by <br /> Repair Work Done ❑ Type of Pump `$_Lj x H.P. S i " State Work Done <br /> Well Destruction Xr Well Diameter } Sealing`Material l top`501 <br /> Depth I Filler Material (BeloW'50'i <br /> TYPE OF SEPTIC WORK: ,NEW INSTALLATION Cl' REPAIR/ADDITIONy❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is <br /> i available within 200 feet./ ✓ <br /> Installation will serve: Residence— (Commercial— Other <br /> Number of living units: Numberof bedrooms <br /> Character of soil to a depth of$feet: i �- Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 1 CapacitNo. Compartments 1 a} <br /> PKG. TREATMENT_PLT. ❑ Method of Disposal / <br /> 1 <br /> Distance to nearest: Well Foundation x Property Line + <br /> LEACHING LINE ❑ No. & Length of lines ' _ =Total length/size, i r <br /> FILTER BED ❑ Distance to Aearest: Well se;Foundation r Property Line"- <br /> SEEPAGE PITS i❑ Depth Size r Number`,i f �I <br /> SUMPS ❑ Distance,-to nearest: Well Foundation W Property Line t " <br /> DISPOSAL PONDS ❑ 's j ' �-' <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, anti <br /> r�rulBs and regulations of the San Joaquin Local Health District. <br /> ,,,__Home owner or licensed agent's signature certifies the following: "I cerdify that in the performance of the work for which this permit is issued, l snail not <br /> 1_­employ any person in such manner as to become subject to-woA-man's-compensation laws of California."Contractor's hiring or sub-contracting sidnature <br /> certifies the following:"I certify that in the performance of the work fo�which this permit is issued, I shall employ persons subject to workman's compen"- <br /> tiori laws of California." L-;- 11 - i s <br /> ->The applicant must call for all re fired i s r '{ <br /> �pections. Complete drawing on reverse side. , <br /> Signed X E Title: Date: t'd-/P-8 <br /> F l j FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date n Area 1 � <br /> Pit k r Grout Inspection by — date Final.Inspection.by- - - Date t <br /> Additional Comments:_ k, �h # - « r ;� f I� t 3 �► �' ` <br /> Y' <br /> El $tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 "Q 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 /> FEE <br /> r" <br /> INFOAMOUNT DUE. AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. <br /> Epi ia-�fREV.,,As UC <br />