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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON 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. 1882 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address c5)F &—L City Lot Size dC PM <br /> Owner's Name Mqwq ��/i�"}�Y!)�� _ ;Addie' _ [ta ZOC/. i. <br /> Contractor's Name License No. f 7 Phone " <br /> TYPE OF WELL/PUMP: NEW WELL ❑ 'WELL-'REPLACEMENT ,❑ --- DESTRUCTION ❑ <br /> f. PUMP INSTALLATION D SYSTEM REPAIR-F❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - '` DISPOSAL FLD. PROP. LINE <br /> :FOUNDATION_ AGRICULTURE WELL -i r <br /> "` OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA. CONSTRUCTi6N SPECIFICATIONS <br /> ❑ Industrial 3 -� ,❑ 0oan'Bottom ❑ Manteca ;Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Piivate ' ``�'❑ Grave!'Pack� ❑ Traci+_. Type of Casing_ ` Specifications <br /> - <br /> 4 Q Public 7 % Q Other ❑ Delta f s Depth of Grout Seal Type of Grout <br /> ❑ Irrigation _—Approz. Depth LI 'Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth Fllle"r�Nlaterial'(Below 50')'� <br />�. TYPE OF'SEPTIC WORK.: NEW INSTALLATION ❑ "REPAIR/AD.DITION' DESTRUCTION ❑ (No septic system permitted if public sewer is i's <br /> available within 200 feet.) <br /> Installation will serve: Residence_V, Commercial_ Other <br /> Number of living units:__Z_ Number of bedrooms _. `` <br /> Character of soil to a depth of 3 feet: <br /> +�. Water table depth O -�- <br /> SEPTIC TANK ❑ Type/Mfg �' Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ s _ Method of Disposal <br /> Distance to nearest: Well a Foundation Property Line <br /> LEACHING LINE No. & Length of lines Z_— .\ Total length size <br /> FILTER BED ❑ Distance to nearest: Well = Foundation., rp Property Line 2© Z <br /> t <br /> SEEPAGE PITS Depth Size ?en Number <br /> SUMPS ❑ Distance to nearest: Well Foundation <br /> AQ Property Line so <br /> DISPOSAL PONDS ❑ <br /> ._(_hereby certify tjhat f 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 follo ing: "I certify that in the perfor ante of the work for which this rmit is issued,I shall employ persons subject to workman's compensa- <br /> f tion laws of C rnia." ,, l <br /> The app!' a for all r wired ' ct' ns. Co late drawing e sided `' cQ <br /> Signed Title., Date: �� O <br /> FOR DEPARTMENT USE-ONL-Y—=--� { <br /> Application Accepted by Date' v Area <br /> top <br /> Pit or Grout Inspection by Data Final Inspection by Date t 7 <br /> Additional Comments: l ', <br /> ❑ Stk 4664781 ❑ Lodi 369-3621 ❑ Manteca. 823-7104 O Tracy,_8215-OM. <br /> t Applicant` Return all copies to: EnvironmentalHealth Permit/Se <br /> —-Applicant rvices 1601 E. Hazelton Ave., P.O.,,Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CCK* RECEIVED BY DATE PERMIT`NO. <br /> 4 + EH 13-24 EH 1428{REV.101831 S �J q - /� _r9 <br />