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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 1 ___61 <br /> ° 1601 E. HAZELTON 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 Coun Ordinance No.549 forsewage or No. 1$62 for wetl/pump and the Rules and Regulations of the San Joaquin f <br /> Local Health District. A-PP 1 i�— Q&Q— 0 e `Sb-54, �,sf <br /> AZT f,4 6d+/Ak--r p r�✓C/&'/11 5vezrr C <br /> Job Address L �GCTD t � City Lot Size r4 Z �f �PM <br /> Owner's Name I b n P, .5-&T;5' Address 344 f r� -� �� Phone ZW1 `3$y <br /> Contractor S(C67W-W Address 2125-0 �y 77_Pr License No.W_52i"8 Phone ' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT I❑ 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 <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 /> F] Public Other ❑ Delta Depth of Grout Seal Type of Grout"'. 61Go i�� <br /> YV6141G <br /> I I Irrigation Approx. Depth i I Eastern Surface Seal Installed by in�j° :— <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Weil Destruction ❑ Well Diameter __.Q,5_ealina Material Itop 50'1 <br /> Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION ['1 �`l r ;m permitted if public sewer is <br /> 2110 feet.l 1 <br /> installation will serve: Residence_ Commercial r <br /> Number of living units: Number of bedroom p <br /> n✓rt>i <br /> Character of soil t4>a depth of 3 feet: / f3 ale depth <br /> SEPTIC TANK ❑ Type/Mfg partments <br /> PKG. TREATMENT PLT. ❑ / f' )f Disposal <br /> Distance to nearest: 'l Q tN L( ¢�r <br /> LEACHING LINE Cl Na. & Length of lines _ bCkt k <br /> FILTER BED ❑ Distance to nearest: <br /> SEEPAGE PITS I I Depth 111 <br /> SUMPS LI Distance to nearest: <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application c `tin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Healt h <br /> Home owner or licensed agent's signature certifies the­ronrn.,U—. o 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 a 1 ornta. or'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." 4 <br /> I <br /> The applican s�c�a I,fg�all required inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> F R DEPARTMENT USE ONLY '1 <br /> Application Accepted by Date Area r <br /> Pit or Grout Inspection by Date Final Inspection by j Date a <br /> Additional Comments t.v t V y e G o— P A "T. ' G 1�� C � i <br /> C ( _ �e !0 w n ,fi c __+10 <br /> n c 10 rn <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 Tracy 835-6385 r 1 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE <br /> I <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> 1 <br /> + EH 13-24 4REV.1 i N s: I O S <br /> E$j 14-26 �.3 G <br />