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r <br /> i <br /> u APPLICATION FOR PERMIT , , <br /> s SAN JOAQUIN LOCAL HEALTH DISTRICT Xl LIC <br /> 1601 E. HAZE l <br /> ON AVE., STOCKTON, CA <br /> -Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t'" y <br /> (Complete in Triplicate) ` : f x �NViRONV1-tAIL HEALTH <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herer�1t52tf E�f�plication is ` <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health Distric#: _ r, t + <br /> 4 Job Address � is • i�V JN ikLL)64 City` JE%S� Lot Size �yry PM ' <br /> Owner's Name-MM=- 4 C K.A1�!� Address 90 P77 Phone <br /> 'Contractor 7W.Siff%dAl LC dol Address c2d2413 A )A) 4790!0 <br /> License No.2Phone <br /> TYPE OF WELL/PUIVLPi NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> ' PUMP INSTALLATION _❑ � SYSTEM REPAIR._ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> J FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE;ORWELL PROBLEIIA AREA CONSTRUCTION SPECIFICATIONS% <br /> ❑ Industrial q Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 'ADomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing a 'Specifications <br /> ❑ Public .-.❑ Other ❑ Delta � Depth ofrGrout Sea] Type of Grout <br /> El Irrigation <7L—Approx. Depth El Eastern' Surface Seal;lnstdlled by'j� <br /> Repair Work Done XType of Pump �— 1H.P. a I "•! State Work Done � [1 <br /> Well Destruction ❑ Well DiameterSealing Material jtop'k') <br /> v,r� 1 G <br /> Depth IFiller Material (Below 50`}S ` ! i'e 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION.❑ DESTRUCTION D)(No septic system permitted if public sewer is <br /> s available within 200,feet.) <br /> Installation will serve: Residence_ Commercial_1 Other i <br /> _-..._..-Number_of_living-units;.-- Number of bedrooms^- �- ` <br /> Character of soil to depth of 3 fe <br /> s, r a , c tet Water table depth <br /> SEPTICJANKA, j. e ,� 4�.;t ,�,.! ,� trtt� <br /> O; 4 Type4/Mfg Capacity t 3 No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method.of.,Disposal <br /> Distance to nearest: Well Foundation �► Property Line <br /> LEACHING LINE ❑ No. & Length of lines q Total length/size <br /> FILTER BED ❑ Distance to nearest: Well FoundationProperty Line h � <br /> SEEPAGE PITS ❑ Depth SizeNumber 4i <br /> >.' ; <br /> i SUMPS ❑ .Distance to nearest: Well Foundation. Property Line <br /> DISPOSAL PONDS ❑ t <br /> hereby certify that I have prepared this application and that thea"work'wilf tie done in accordance wiifi 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%�orkman'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." j <br /> i <br /> The applicant call for IIrequir ;inspreons. Complete drawing on reverse side. / <br /> Signed Title:�tNt� Date: "7/f_/ lOnj�? <br /> DEPARTMENT USE ONLY } <br /> "Application Accepted by' Date ��/� Area <br /> Pit or Grout Inspection by Date Final Inspection by/�� Date 51-.22-sq <br /> LZ <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 0400 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO.. <br /> INFO <br /> + EH1 -24fREV. <br /> t/es) <br /> EH 1426 <br />