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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone {2091 466-6781 <br /> z <br /> PERMIT EXPIRES TYEAR 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 t <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 �jt� ofD City TQ)P Lot Size f PM <br /> or _ S �uT6sc <br /> Owner's Name k j Address �� 'kA 1A.7 ""Ci-L - Phone dlfo� <br /> Co r er __ - �"Adtlress -r L0, ��" ` "- Lic'ense_No.a1/ o2__Phone `9 <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 PITSISUMPS. _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1-1 Public ❑ Other ❑'Delta Depth of Grout Seal = Type of Grout <br /> I I Irrigation _..Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done'"`d, Type of Pump H.P. State Work Done"_ <br /> Well Destruction ❑ '`Well Diameter Sealing Material Itop 50'1 <br /> Depth Filler Material-IBelow 50'1 - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION'4 DESTRUCTION I I (No septic'system permMed.if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_e Commercial— Other <br /> 1 <br /> Number of living units: ___ Number.af_bedrooms.11_ <br /> Character of soil to a depth of 3 feet: Water table depth'. <br /> SEPTIC TANK ❑ Type/Mfg iL� rapacity- No: Compartments' ! <br /> _. <br /> PKG. TREATMENT PLT. ❑ - Method of Disposal <br /> Q <br /> s Distance to nearest: Well `}6_ Foundation J - Property Line <br /> F -_ <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> i �' - " <br /> j FILTER BED El Distance to nearest: Well <br /> �✓y tFoundation Property Line- r <br /> i SEEPAGE PITS I i Depth Size Number <br /> I SUMPS D Distance'to nearest: Well '- Foundation-- Property Line <br /> i DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this applicationand that the w6r"k;will be done-inaccordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin-L-ocal"Heakh-Di§trict. � _ <br /> Home owner or licensed agent's signature certifies the following: "I ctirtify thaf in'ihe 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"subiect to workman's compensa- } <br /> t <br /> tion laws of California." <br /> i a <br /> The applicant must call for II required inspections. Complete drawing on reverse side:: r "•., <br /> Signed X / Title:' ' /Zr.'o_;�% "" IDa.a. !"U <br /> -�: _ <br /> F F DEPAfi ENT USE'ONLY' <br /> / p <br /> Application Accepted by Date ' a <br /> Pit or Grout Inspection by Date Final Inspection by Data�� a <br /> ` Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104_ ❑ Tracy 835-6385 k <br /> Applicant _Return all copies to: Environme6tal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> �eK_ _ _�._�—,�. —.__. <br /> -. __.- FEE - RECEIVED;BY DATE PERMI7 NO. <br /> - INFO AAAOUNT-DUE"'"`P ;-. AMOUNT REMITTED r"CASE!'` <br /> ..+�!.. <br /> ♦.EH^13-241REV.I K51�.... .- - - { � C1 CTO <br /> EH t4-2e <br />