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w <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> :.. # <br /> 1.601 i E�HAZE�T ON AVE., STOCKTON, CA U� <br /> ' Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR I ROM DATE ISSU � 1989 <br /> (Complete in Triplicate) <br /> t •. ` - <br /> 'I � T 1s applicationYis <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install <br /> � 5 <br /> Rmade in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for wellipump and the u es and Regulations of the San Joaquin <br /> Local Health District. Q f <br /> Job Address 157 ,p/ E y City �`m- °�1 Lot Size PM <br /> �J ° �N Phone / <br /> Owner's Nam t Address <br /> Of <br /> ` 7 License N �Phone <br /> 7 7- ` <br /> Contract Address <br /> I TYPE OF WELL/P P: NEW WELL ❑ f WELL REPLA EMENT El DESTRUCTION 17t PUMP INSTALLATION ❑­ R SYSTEM REPAIR OTHER❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION 'AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL ,PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r ❑ Industrial Open Bottom r w._.❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy xy• Type of Casing Specifications <br /> F] Public n Other CI Delta ; Depth of Grout Seal Type of Grout <br /> Repair <br /> Irrigation _._Approx. De th Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pumpkill <br /> H.P. %, State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material-}top 501 � <br /> Depth "Filler Matetial (Below 50') 4 ^� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION {1 REPAIR/ADDITION ! 1 DESTRUCTION i I (No septic system permitted if public sewer is G <br /> _ _.. available within 200 feet.) �l <br /> Installation Wilt serve:"`"Residence=""Commetcial:_-- 'Other o-"M <br /> A 'Number of living units: �­Number of bedrooms 1 <br /> Character of sail to a depth3of 3 feet: " ' Water table depth <br /> A' SEPTIC TANK ❑ Type/Mfg � Capacity ° No. Compartments <br /> PKG. TREATMENT PLT. ❑ M Method of Disposal <br /> r f <br /> Distance to nearest: Well Foundation 6 Property Line <br /> LEACHING LINE ❑ No. & Length of fines f Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> I i <br /> SEEPAGE PITS 1 1 Depth Size r _ Number <br /> � SUMPS ❑ Distance to nearest: Well r.. Foundation Property Line <br /> ,TDISP_QSAL_P_ONDS.� ❑ , _ - _ ,- ,.---• °� �- t -: . <br /> 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. =:-1y---� d <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 tow"orkman's compensation laws of California." Contractor's hiring or subcontracting 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 st call for all re red ins_ ctigris. Complete drawing on reverse side. <br /> a 3 r <br /> i <br /> Signed X Title: Date: <br /> r OR DEPARTMENT USE ONLY <br /> 17— <br /> Application Accepted by Date Area <br /> _ I <br /> Pit or Grout Inspection by Date Final Inspection b Date�� <br /> r <br /> r y - <br /> Additional Comments: " - <br /> ❑ Stk 466-6781 ❑ Lodi .369-3621 ❑ Manteca 823-7104 Tracy 1335-63_$5 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave:, P.O. Box 2009, Stk.,'.CA 95201 <br /> i <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY 'DATE PERMIT'NO. <br /> INFO � p <br /> +.EH13-241RIV.1/x51 ,3s<OO 1114 �ttJO <br /> EH 14-28 <br />