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��. <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT f <br /> '• 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telepho6e (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.,y' �� � � �I �� <br /> So.iTh OT 16- IA)6f � I p j ° 1 �{ <br /> Job Address whoa l�eor City' tot Size 7 PM , <br /> 0 5' ns Cr•e BW $u, Z7s- <br /> Owner's Name A n _tea e �5�, Address Sun- ��aS G, ��Z� Phone — 00 <br /> �"�+ r go'd <br /> Contractor on Address 5+� License No, FO Z Phone 416--)930 <br /> TYPE <br /> 6-- 0TYPE OF WELL/PUMP: NEW WELL ❑ WE L REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK 515-0 161D .,ell <br /> SEWER LINES '>ISV r DISPOSAL FLD.�ISO r PROP. IN �l9�V � <br /> FOUNDATION 15� r AGRICULTURE WELL � OTHER WELL a� PITS/SUMPS ISt7 l <br /> INTENDED USE N# TYPE OF WELL�/� PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial r ❑ Open Bottom r ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f T Public I 1 Other Cl Delta Depth of Grout Seal! u Type of Grout `IIt _ <br /> 1-1 irrigation _Approx. Depth I I Eastern Surface Seal Installed by oU1�nr� <br /> Repair Work Done ❑ Type of.Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth IO-2.0 '�ejt- Filler Material (Below 501 �! <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I:] REPAIR/ADDITION I ] DESTRUCTION I 1 (No septic system permitted if public sewer is R r <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 Capacity No. Compartments y <br /> PKG. TREATMENT PLT. ❑ Method of Disposal jJr <br /> Distance to nearest: Well Foundation Property.Line e <br /> LEACHING LINE tilA ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS n Depth Size Nh-i l 1 _ <br /> Number <br /> SUMPS I ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ' ❑ <br /> 1 hereby certify that t 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 Diltrict. <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 m st colt for all required inspections. Complete drawing on reverse side. F <br /> Signed X Title: r -/� Date: ' <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date <br /> Pit or Grout Inspection by Dater5'� Final Inspection by Date }1114 <br /> Additional Comments: i <br /> ❑ Stk 466-6781 ❑ Lodi . 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i <br /> Applicant. Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95.201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO RECEIVED BY DATE PERMIT NO. <br /> CASH <br /> t k <br /> +.EH 1 -24 iREV. <br /> EH t44 �-?-28 - S. C /S <br />