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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> y (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., r, ;C y' <br /> ' Job Address "Po A,YI! City S7v Lot Size M <br /> Owner's Name Add..ress eV Phone <br /> Contractor 5��� Address -54 J'V( License—Na_­----!- Phone <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT.❑ DESTRUCTION ❑ <br /> k PUMP INSTALLATION ❑ SYSTEM REPAIR"❑ THER D <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWE ES <br /> j r DISPOSAL FL PROP. LINE <br /> FOUNDATION AGRICULTU ELL I OTHER L'- ;,I PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONS UCTION , IFiCATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca -Dia.,of,., ccavation Dia. of Well Casing W <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T f Casin �-- - i - -.Specfications <br /> ❑ Public E Other ❑ Delta Depth of Grout Se Type of Grout <br /> L-1Irrigation ---Approx. Depth ❑ Ea Surface Seal Installed by t-w1 <br /> Repair Work Done ❑ Type of Pump H.P. _s State Work Done <br /> . � v <br /> Well Destruction ❑ Well Diameter Sealing Material itop; <br /> � 50,1,t (VJ <br /> Depth Filler Material lBelow.501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION W (No septic system permitted if public sewer is <br /> k available within 200 feet.) <br /> { Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms 1 <br /> Character of soil to a depth of 3 feet: I Water table depth r, <br /> SEPTIC TANK Type/Mfg Capaci No. Compartments <br /> P PKG. TREATMENT PLT. ❑ i Method of.Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size'';" , <br /> - FILTER BED ❑ Distance to nearest: Well Foundation a Property Line' <br /> ir <br /> SEEPAGE PITS Depth Size --'—Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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, 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 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." t <br /> The applicant must call for all requir ins tions. Complete drawing on reverse side. ` <br /> i <br /> i, igned Title: /�L.. 4 Date: 3 S <br /> ..� <br /> FOR DEPARTMENT USE ONLY <br /> njoApplication Accepted by .- . 4 %-? Date I Area Q. <br /> ,. <br /> Pit or Grout Inspectio Date Final Inspection by Date <br /> Additional Comments: ;' d"^, -�-6--t El Stk Stk 466-6781 ❑ Lodi- 369-3621 ❑ MnWca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copi to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> C 12-J 8-& -­,;rC)(C--i/C C Ave :�5-S i7- /LfIrl . &A G11- <br /> FEE <br /> mowFEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'Nif <br /> INFOt*aw <br /> + EH 13-24[REV.t/a sl �� v `� h +'� /��� ..� <br /> EH 1428 _ ,_..] ) <br /> `r 1 "-7 a -CA2-*­- J1 S3 <br />