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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> 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 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 /> Local Health District. <br /> Job Address rV City fes. Lot Size . PM <br /> _ r <br /> Owner's Name HS< L,4_9Grma J`"k Address J Phone �f <br /> Contractor e �� e{"'tiL.-[--C+tF-�_Addresses z / License No. Phone 7` <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 PITS/SUMPS _r <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 /> M Public ❑ Other ❑ Delta Depth of Grout Seal Type,of Grout <br /> I i Irrigation �.Approx. Depth ' :,I I-Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P, State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material itop 501 r <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within$00 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: A ®n l?6 Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 22262-- Capacity l,No. Compartments <br /> PKG. TREATMENT PLT. ❑ `� Method of Disposal <br /> Distance to nearest: Well 7G Foundation Property Line __ <br /> LEACHING LINE No. & Length of lines ��� Total length/size �! <br /> FILTER BED ❑ Distance to nearest: Well/!d Foundation =�Property Line A <br /> SEEPAGE PITS I I Depth /40/-7 _ Size �X'IQ� Number <br /> SUMPS Distance to nearest: Well ATO. 7 Foundation qo ., Property Line <br /> DISPOSAL PONDS ❑ ' <br /> I hereby certify that I have prepared this application and that the work will he done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <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 /> 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." <br /> The applicant must/call for required inspections. Complete drawing on reverse side. T <br /> Signed X�T� ! is _ Title: Date: /.io <br /> Op DEPARTMENT USE ONLY <br /> Application Accepted by Date C Area j <br /> Pit or Grout Inspection by bate Final Inspection by Date/ <br /> Additional Comments: <br /> ❑ Silk 466-6781 ❑ Lodi 36.9-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. <br /> +.EH 1 3-2 4(REV.t i w 5l C:) �9 <br /> - — - _ r - <br /> FH 14-26 - �. _ <br /> $1;x'3317 <br />