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< APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Zr1 1601 E. HAZEL T ON AVE., STOCKTON, CA c <br /> L'.-- Telephone (209) 466-6781 J� <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. f�ii20 S <br /> Job Address .350 City � Lot Size PM <br /> Owner's Name �— �-/ Address Phone <br /> Contractor k&JJA Address 3,50 C_ L License No. q ' Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Qyr.cr- <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 l <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �J�1 <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f'1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —_Approx. Depth I I Eastern Surface Seal Installed by _ C <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 14-4e—septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: T <br /> ce�'Commercial ther <br /> Number of living units: Number of bedrooms <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 /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 /> ifies 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 s of Calif 'a." <br /> The applic must ca for I requ d ins Complete drawing on r verse side. ��?J <br /> Sig Title: �/° Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Dat �� Area <br /> i1y l <br /> l � i ��i !4 Uj ! I <br /> Pit or Grout Inspecti y Date nFinal In %�- <br /> Inspection by r�,�-f � ?,r"�?�' Date <br /> Additional Comments: U n <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 11217104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE /AMOUNT REMITTED CASH CK 9 RECEIVED BY DATE PERMITNO. <br /> + EH 13-24(REV.I/H 5) _ 2� 1J(� r A/-� ­7-3 <br /> UA <br /> EH 14-26 <br />