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1 ° <br /> 43 ) p3Z <br /> APPLICATION FOR PERMIT <br /> P.l 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 Lot Size PM <br /> Owner's Name'L� �' G Z-44-Address Phomas — 03x3 <br /> �fL»ns1 p� <br /> Contractor's Name(2AN04&4 ej�'4 License No. Phone �- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ V <br /> PUMP INSTALLATION ❑ SYSTEMIREPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE W <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 PumpH.P. State Work Done <br /> Well Destruction ❑ Well Diameter' `" <br /> Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCT40Pk❑--+14o sept4-$Xstem permitted if public sewer is <br /> -A' available wit -irf 2W feet.) <br /> . esideei cd'= Commercial Other (- y� IM <br /> Number of living units: Number of bedro ms <br /> Character of soil to a depth of 3 feet: Q W, "' - "'" Watei table depth V <br /> SEPTIC TANK A---T-ype/Mfg Capacity_ No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1 / i Method of Dispssal <br /> Distance to nearest: Well - - Foundation l b Property Line _ } <br /> LEACHING LINE No. & Length of lines 01%R-1 Total length/size 7, L_ <br /> FILTER BED ❑ Distance to nearest: Well Vii_ Foundation + (U Property Line + <br /> SEEPAGE PITS Depth Size Number 21 <br /> SUMPS ❑ Distance to nearest: Well Foundation 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 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 Kirin or ontracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I-shall employ pear ns su ject to workman's compensa- <br /> tion laws of California." _ <br /> The app' a IF inspections Z " on reverse side- <br /> Signed Title:42�!a�� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted y Date G� �3 rea G�� <br /> Pit or Grout Inspectio y Date Final Inspection by to <br /> Additional Comments: j <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CAH CK RECEIVEDBYDATE PERMIT NO. <br /> + EH 13-24(REV.10/63) Is <br /> z_13076 <br /> ?0 TEH 14 26 1— �/ 0�7 .f J V <br />