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b <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> ■ 'Teiephone {209} 466-6781 <br /> PERMIT EXPIRES11 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 /> x made in compliance with San Joaquin County Ordinance No:599 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> . <br /> Job Address <br /> City Lot Size S5 %PM <br /> Owner's Name ler, Address 3 T Phone <br /> ContractozPk, TIRV_&1Sk —Address?O 6 License No.2S4. ' Phone 6 ' <br /> TYPE OF WELL/PUMP: NEW WELL E3 WELL.REPLACEMENT ❑ DESTRUCTION ❑ — <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 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 1, ❑ Mante-ca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> 0 Public 0 Other ❑ Deltay Depth of Grout Seal Type of.Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern .Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction 0 Well Diameter t Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑!REPAIR/ADDITION ■ DESTRUCTION ❑ {No septie_system permitted if public sewer is <br /> � -�` <br /> Installation will serve: Residence Commerciah_t1 Other f <br /> Number of living units: _[_ Number-of bedrooms <br /> Character of soil to a depth of 3 feet: Water table=depth <br /> SEPTIC TANK 0 Type/Mfg ' r) I Capacity No.No. Compartments <br /> PKG. TREATMENT PLT. 0ft1 f7A11L —gyp � Udt,, ood +6-p. —`r Method of Disposal a ; <br /> Distance to nearest: ��Well. I Foundation.- _ '} property Line <br /> LEACHING'LINE ❑ No. & Length of lines ` Notal length/size <br /> FILTER BED ❑ Distance to nearest: Well t Foundation- `� "''� Property Line E j <br /> SEEPAGE PITS ❑ DepthSize r w Number 1 1 <br /> SUMPS ❑ Distance to nearest:. Well : Foundation <br /> DISPOSAL PONDS ❑ ./r f r� <br /> I hereby certify that I have prepared this application and tha fthe work will be done in accordance with San Joaquin county ordinances%state laws, and <br /> rules and regulations of the San Joaquin Local Health Dis'trict.. . _ I /� �tf 1 } <br /> Home owner or licensed agent's signature certifies the following: n_e*- l_ <br /> 9 g g: "I certify`that in the performance'of the wo�r c for which this permit is issued, I shall not i <br /> employ any person in such manner as to become subject to workman's cortlpensation laws of California." Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for'which tliis permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." E L'-� t <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed <br /> Date: <br /> V <br /> h FOR DEPARTMENT USE ONLY } <br /> Application Accepted by I Date �a-� � Area <br /> Pit or Grout Inspection by Date Final Inspection by bate <br /> Additional Comments:U1iqJA&A4&W t4 A16 /,,Zm _hint <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ nteca 82 104 ❑ Tracy 835-6385 ,547 �h etP rs P� <br /> Applicant- Return all copies to: Environmental Health Per )s 1601 E. Hazelton Ave., P.O. Box 2009, , CA 95201 -}unC{y.OA <br /> INFO AMOUNT.DUE AMOUNT L�EIUIITTED CASHf <br /> RECEIVED BY DATE PERMIT NO. �` J <br /> + EH13-24 iREV.1/n s> } <br /> EH 14-M ! ( <br />