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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA RECEIVED <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AUG L ? 19R <br /> (Complete in Triplicate) <br /> ENVIRQtV.Zr <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wor i scJ� atrglication is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rul s San Joaquin <br /> Local Health District. _ij <br /> Job Address f-�oN�+�- t� City Lot Size PM <br /> Owner's Name Al-L &Lrne 0- I(;ak Address 416& _T TV-ail i Phone 267 <br /> ContractorAddress - AV License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE ENT ❑ DESTRUCTION ❑ <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 /> FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout __ <br /> I I Irrigation __.Approx. Depth I I Eastern Surface Seal Installed by - f <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 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION (No septic ystem permitted if public sewer is <br /> availab hin 200 feet.) <br /> Installation will serve: Residence_ Commercial /0th <br /> Number of living units: Number of bedrooms 0. <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Ca No. Compartments <br /> PKG. TREATMENT PLT. El ` i p_ Method of Disposal <br /> Distance to •7 '^QIV Foun on Property Line <br /> LEACHING LINE ❑ No. & L h@f Ii �J Total length/size <br /> FILTER BED ❑ Distance to rest: \W I Foundation Property Line <br /> SEEPAGE PITS I I Depth Size... _ Number <br /> SUMPS Ll 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 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." <br /> The applicam� Title:ust call for all required inspections. Complete drawing on reverse side. <br /> Signe- 216Lr'�"�D� Date: <br /> u g <br /> X I�i <br /> FOR DEPARTMENT USE ONLY /� J <br /> Application Accepted by � _ _ Date Area / <br /> Pit or Grout Inspection by Date Final Inspection by ✓/d Date` <br /> Additional Comments: <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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> +-EH 13-241REV.1/851 0 ,O 1 <br /> EH 14-M V /1 <br />