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A APPLICATION,FOR PERMIT <br />SAN JOAO,UIN,LOCAL HEALTH DISTRICT <br />1601 E. HAZE T ON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 <br />qq, 11 1( �e �!y .y y PERMIT EXPIRES 1 -YEAR.FROM DATE ISSUED - ` - <br />4pii8.F cls-v{o$1i' Gi:'.s 9'- WNY:ar 3 <br />c,� ��,�.,��:r�,�.,, ,� �x: �-�: (Complete.in Triplicate) <br />Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install rthe work herein described. This application is <br />,made in-compfiance 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 DistnctT <xiBr . J �� r t " , :t" - y:>� �., <br />Job Address _7��25/ O Pi'/g N`G ../✓ v F .t . ; , 2 <br />- City i /� Lot Size ',*C � .. p <br />Owner's Name C;0 8' ; <br />• - 4 . Address Phone '?' � •" a .3 <br />_ . Contractor's Name i License No. Phone <br />647 <br />{ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ y� i <br />PUMP INSTALLATION ❑ SYSTEM REPAIR CIOTHER El_J <br />'3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.PROP. LINE <br />° FOUNDATION AGRICULTURE WELL OTHER WELL PITS/Si1MPS <br />INTENDED USE TYPEOFFWWELL 0 LEM AREA CONSTRUCTION' SPECIFICATIONS <br />}. ❑ Ind(Orial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of \Nell Casing <br />❑ Domestic/Private ❑ Gravel Pack El Tracy T ' <br />Y ype of Casing Specifications <br />❑ Public ❑ Other ❑Delta Depth of Grout Seal T <br />ype of Grout <br />❑ Irrigation—L—Approx. Depth ❑ Eastern Surface Seal Installed by ! <br />Repair Work Done : ❑ tType of Pump tH.P. State.Work Done <br />-� q, } •v <br />Well Dest"ruction ❑ Well Diameter Sealing Material (top 50'1 .� } <br />! Depth';: Filler Material {Below 501 <br />TYPE OF SEPTIC WORK: NEW,�INSTALLATION REPAIR/ADDITIQN ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r1 <br />i available within 200 feet.l <br />Installation will serve: Residence L/' Commercial Other <br />Numberr living units: #Number of bedCooms__ s <br />Character of soil to a depth of 3 feet: _ #�- --= - -- ---M-- -�'..r Water,table depth --'o <br />SEPTIC TANK ®Type/Mfg Capacity—zZe-10 No. Compartments i <br />PKG. TRIATMENT ?LT. ❑ Method of Disposal: <br />Distance to nearestyy: Wells'=^Fullatio7l%D----W-propertq'Line�" <br />/_ <br />LEACHA LINE 0 No. & Length of lir) AS, _ . .� .5� Total length/size 2 <br />FILTER BED ❑ Distance to nearestN Le 'Well Foundation _n" Property�.0 T <br />SEEPAGE PITS YDepth �J��t" _Size <br />Number <br />SUMPS ❑ ' Distance to nearest: -Well rill 't <br />..� Foundation �5 0 _Property Line <br />DISPOSAL PONDS ❑ <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 andl regulations of the San Joaquin Locak"galth District: t.. <br />Home owner or licensed agent's signature cereffies the follow ing: "I certify that in the performance of the work for which thisiperm`t is, issued, I shall not <br />employ any person in such' manner'as to become subject to workman's compensation laws of California." Contractors 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 Caflfornia.'r f t <br />The applican st.call for all required ' s n Complete drawing on reverse side. <br />i Signed Title: - f <br />s _ Date:. Il Z k 4 <br />•' V \ <br />Fy^",+ FOR DEPARTMENT USE ONLY g <br />! tApplication Accepted by' - - �y> }r, <br />-l. .. Date ' Area <br />i Pit or Griut Inspection by 1� Date R ttFinal Inspection by `r c��" Date <br />mAddition Comments: "�v[ Gr�►� <br />--� E] Stk 1 El Lodi 369-3621 ❑ Manteca 823-7104 - i ❑ Tracy 835-6385 <br />Applicants - Return all copies to: Evironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br />' INFO AMOUNT bUE r , AMOUNT REMITTED CK „ RECEIVED BY DATE PERMIT"NO. <br />CASH <br />t <br />'+ EH 13-24 (REV. I U834 <br />EH 5428 e qsl <br />