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a_ <br /> APPLICATION FOR PERMIT el <br /> -- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> L(� 1601 E. HAZE; TON 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 9,05 <br /> t� City Lot Size PM <br /> Owner's Name � - Address t'+til _ �• Phone <br /> i =�S <br /> pi _• ro:r� ss 1 / License hon <br /> r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 7' OTHER ❑ # ` <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.. --- PROP. LINE <br /> 1 FOUNDATION `° + AGRICULTURE WELL OTHER WELL v PITSISUMPS 1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREAL, CONSTRt1CTION SPECIFICATIONS <br /> ❑ Industrial•` ❑ Open Bottom ❑ Manteca Dia-of We Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack-�-�-O-Tracy Type of Casing Specifications <br /> /f,],Public I` i F k Other 11 11 Delta' Depth of Grout Seal Type of Grout t� t <br /> I I Irrigati n f _._Approz. Depth l I Eastern Surface Seal Installed by _ ` <br /> Repair Work Done ❑ Type of Pump L�H.P.------ State Work Done_ r <br /> I � r i I <br /> t ir Well Destruction ❑ Well Diameter Sealing Material Itop 50,') I <br /> i Depth # ,Filler Material (Below <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I=1 REPAIR/ADDITION DESTRUCTION I'I,INo septic system permitted if public sewer is .1 <br /> aF v ava6ble.within 2W feet.) <br /> f t <br /> Installation will serve:`-Residence_ Commercial' Other <br /> Number.ol_living units:' ;:Number of.bedrooms - <br /> Character of soil to a depth of 3 feel: Water table depth <br /> SEPT[C-TANK---«r---1 r❑—Type/Mfg � I" _ - p r � No. Compartments <br /> PKG:"TREATMENT PLT. ❑ 1d.} Method of Disposal <br /> del <br /> Distance to nearest: W 1 Foundation Property Line <br /> LEACHING LINE ❑' No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: ell ifr1�- foundation e Property Line - <br /> ��a � a <br /> SEEPAGE PITS I ],Depth Number <br /> SUMPS r -L7 W Distance to nearesti Well- Foundation 9 _....._.-_ Property Line { <br /> ,DISPOSAL_PONDS -❑Y_ <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. F <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."Contractors hiring or sub-contracting signature <br /> certifies the following! '3 certify that in the performance of.the'work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> i do i laws,of California." <br /> The applicant us(ca111for qulred-i p�ections. Complete drawing on freverse-side <br /> t Signed X - Title: Date <br /> li <br /> FOR DEPARTMENT USE ONLY t <br /> ! Appiicafion Accepted by Date Area <br /> Pit or Grout fnspe a Date Final Inspection by'n, �­T-, r�.. c Date 71 t <br /> Additional Comments: , <br /> ' O Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave:,-P.O:Box 2009,-Stk.,-C-A 95201 <br /> INFO <br /> AMOUNT DUE AMOUNT REMITTED CASK RECEIVED BY / DATE PERMIT NO. <br /> + EH 14-28 IRM r/H 5) /v 7- <br />