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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E.HAZEL.TON AVE.,STOCKTON,CA <br />Telephone (209)466-6781 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />Application is heiebv 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 3"200 E'r1-J..:t-m t 1"'(go C<.,}City .5'to~Klr:..,Lot Size PM , <br />INTENDED USE <br />o Industrial <br />o Domestic/Private <br />n Public <br />~Ir~~ltc~~'l-l "-,~II <br />Repair Work Do11e [J <br />Well Destruction 0 <br />TYPE OF WELL <br />o Open Bott0":l <br />f8.Gravel Pack <br />n Other.I6.£:.Approx.Depth <br />Type of Pump <br />Well Diameter <br />PROBLEM AREA <br />o Manteca <br />o Tracy <br />KDelta <br />{I Eastern <br />Phon( <br />Owner's Name ..J.Tf...!r-L1 ---'V!:....!cJ~/-"7~.-I.oi6=c:::.!:.,,-....!<!L-"'''Y<''''''':::...-.•••:S"L-_Address <br />TYPE OF WELL/PUMP:NEW WELL WELL REPLACEMENT 0 DESTRUCTION 0 , <br />PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 2 .3 S <br />DISTANCE TO NEAREST:SEPTIC TANK SEWER LINES DISPOSAL FLD.PROP.LINE __ <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />CONSTRUCTION SPECIFICATIONS <br />Dia.of Well Excavation 8 '/1\.,Dia.of Well Casing <br />Type of Casing pl./G Specifications <br />Depth of Grout Seal I(2 -ft Type of Grout~.:t-C~~~m <br />Surface Seal Installed by ..!I(..()dL=~.c::~~-=---______________\ <br />H.P.State Work Done <br />Sealing Material (top SO') <br />Filler Material (Below 50')Depth <br />TYPE OF SEPTIC WORK:NEW INSTALLATION I 1 Afl'AIA/ADDITION {I DESTRUCTION {1 (No septic system permitted if public sewer is <br />available within 200 feet.) <br />Installation will serve:Residence __Commercret __ <br />Number of living units:__Number of bedrooms _ <br />Character of soil to a depth of 3 feet:Water table depth ----------1 ..•... <br />SEPTIC TANK 0 Type/Mfg Capacity,______No.Compartments <br />PKG.TREATMENT PLT.0 Method of Disposal ---------h <br />Distance to nearest:Well Foundation Property Line _ <br />Other _ <br />LEACHING LINE 0 No.&Length of lines <br />FILTER BED 0 Distance to nearest:Well Foundation <br />SEEPAGE PITS II Depth Size <br />SUMPS Ll Distance to nearest:Well -Foundation <br />DISPOSAL PONDS 0 <br />______________Total length/size -l <br />Property Line _ <br />Number _ <br />Property Line _ <br />I 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 0 become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br />certifies the following:"I certify hat i the performance of work for which this permit is issued,I shall employ persons subject to workman's compensa- <br />tion laws of Cali " <br />e drawing on reverse side. <br />Signed "-_+-__-==-----"-=-¥-L-...,.....oL..-_"---_Title:C11 /l~t ~tf.-tt 10.,;-1~t-3861f Date:1/;s/8'K' <br />:'?~~;::=:USE ONLY <br />-1G-"~o,QI•••••CMA""""---'~~=--~~~Date q --"2-"L---e€J Area~~7_Application Accepted by <br />Pit or Grout Inspection by Final Inspectio by _ <br />Additional Comments:..----.,C}~ <br />o Stk 466-6781 0 L'-3621 0 Manteca 823-7104 0 Tracy <br />Applicant -Return all copies to:Environmental Health Permit/Services 1601 E.Hazelt <br />Date _ <br />r-. <br />5-6385 <br />Ave.,P.O.Box 2009,Stk.,CA 95201 <br />•EH 13·24 IREV.II H 5 <br />EH 14·26 <br />FEE AMOUNT DUE I AMOUNT REMITTED CK It RECEIVED BY DATE PERMIT'NO.INFO CASH <br />I I~-<;_(j:)~tIP 35 .(o/'b I(Y1~~~Pr·IOIIQI~~~~,.;J(pp <br />,