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APPLICATION FOR PERMIT <br /> a , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON 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 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 City 4 Lot Size ' PM <br /> Owner's,-Name—g /110,4Address "r �� � °►•Phon C <br /> rr. , x;15°ct C1Ct� 0 2-z(P Phone 6 -1�� <br /> Contract Address � License No.62 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r <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 /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _-- <br /> Well Destruction �t__Well Diameter F Sealing;Material {top 501 .r . <br /> Depth filler Material•(f3elow 50') � --•' _ - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPA /ADDITION DESTRUCTION ❑ (No septic system permitted.if.public-sewer_is._�_ <br /> --✓-- ---- —� available within"200 460-­ <br /> Installation will serve: Residence— Commercial Other . .. jh <br /> Number of living units: Number of be roams <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> -n -, <br /> Distance to nearest: .Well Foundation Property Line <br /> ` <br /> LEACHING LINE No. & Length of Iines Toiahlength/size- <br /> FILTER BED istance to nea est: r-•-Well --�Fc)undation----�- ---rProperty Line <br /> 'SEEPAGE PITS ❑ Depth 1 Size 9 X 36 Number <br /> SUMPS Distance to nearest: Well Foundation /(i �'F Property Line .S✓ <br /> DISPOSAL PONDS ❑ c =r`` <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 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 Lo workman's c6 <br /> tion laws of California." <br /> The applicantt call fora equ' d inspections. Complete drawing on reeler <br /> Si ed Title: v Date:c2Z/11 <br /> F R DEPARTMENT USE ONLY <br /> Application Accepted by lj/ Date c L Area <br /> I i''. <br /> Pit or Grout Inspection by Date Final Inspection by �U!/al"i'ca Dateg�� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 4 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,iStk., CA 95.201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CKRECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> j + EH 1324(REV.t/as) —7c> -/��{ �"'� <br /> EH 14.26 ! -f <br />