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APPLICATION FOR PERMIT "" ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 ,E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> ` PERMIT EXPIRES 1 YEAR-FROM DATE ISSUED <br /> L- (Complete in:Triplicate) ,- r <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 /> 1,? Local Health District. <br /> Job Address � �. CityLot Size PM <br /> 40is 9 s S�v7 <br /> -_ la/, > Address ! Phone � � ~�� , <br /> Owner's Name- (� <br /> Contractor.} p✓ 0 Address ✓ License No. 37-1�y�Z Phone 2� a <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ <br /> LLA <br /> PUMP INSTATION ❑� ` SYSTEM REPAIR 0TH ❑ I <br /> DISTANCE TO NEAREST: SEPTIC TANK .._ SEWER LINES DISPOSAL FLDPROP. LINE <br /> FOUNDATION '_ - AGRICULTURE WELL OTHER WELL.PITS/SUMPS <br /> ` <br /> INTENDED USE TYPE OF WELL PR j3LEM AR EA° CONSTRUCTION`SPECIFICATIO " <br /> [j <br /> ❑ ndustrial 1 ❑ Open Bottom anteca Dia. of Well Excavatio - �- Dia.;of Well Cason ' <br /> V.' 760 0117' <br /> omestic/Private ravel Pack- ❑ Tracy Type of Casing 1 Specifications <br /> ❑ Public ❑ OPer ❑ Delta ; Depth of Grout Seal Type of Grout <br /> t 17Irrigation 7�� 4pprox. Depth ❑ Eastern i Surface Seal Installed by LcJ <br /> i Repair Work Done ❑ Type of Pump H.P. ' State Work Doris <br /> Well Destruction ❑ Well.Diameter �'"'�'�`""'"�fSealing Material (top 501 <br /> Depth i }� _ _— Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW,'INSTALL:ATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo 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 t Capacity A"51. "+ ("`', :Noy Compar3rreents <br /> a - <br /> PKG. TREATMENT PLT. ❑ ,,.._. Method of Disposal <br /> ... ;-�.. <br /> Distance to nearest: Well Foundation Property Cine , <br /> �A %M <br /> LEACHING LINE ❑ No. & Length of lines ..Total length/size <br /> FILTER BED Ll Distance.to nearest: Well Foundation '�'" Property Line <br /> R y <br /> SEEPAGE PITS ❑ Depth ^t Size Number ._ <br /> SUMPS ❑ Distance to nearest: Well ° Foundation Property Line <br /> } <br /> 3 <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,-st�te laws, and <br /> rules and regulations of the San Joaquin Local Health District. s <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 /> i 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 workmans compensa <br /> tion laws of California." " <br /> The applicant mus all r u' d i spections. Complete drawing on re erre side. ` > <br /> Signed T Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Applicatio ccepted by t=J� Date Area r <br /> Pit or rou nspection by Date <br /> g� Final Inspection by Date a <br /> *iL <br /> L117 -011- PL(I-20 <br /> ywl <br /> k ✓ 1 Additional Comme s: ° <br /> ❑ Stk 466-6781 ; ❑ Lodi 369-3621 -❑ Mant 8x1 104 Tracy ; © fjLP�! <br /> Applicant- Return all;copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.; P,O. Box 2009, Stk., CA 95201 4 <br /> v.�- • .11- I N 1 <br /> k FEE AMOUNT DUE AMOUNT REMI rE4 CK RECEIVED 9Y DATE PERMIT"NO. <br /> INFO CASH <br /> 7 i + EH 1324IREYp1/asl <br /> 1 ` EH 14-26 <br />