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S _ <br /> �J <br /> APPLICATION FOR PERMIT <br /> n SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> !/ 1601 E. HAZE:.TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781. <br /> PERMIT EXPIRES 7 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 Sizef_W� = PM <br /> Owner's Name - SC Address _� / ?� AeV Phone <br /> Contractor's Name — 141'L l 17211a License No. .2 �J 6�� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑- DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industr'ial '- ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Pia. of Well Casing ' <br /> 11 .❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> O-Public ❑ Other ❑ Delta 7 Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Easternr Surface Seal Installed by �l <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') - -- •- <br /> Depth Filler Material (Below 501 ' f° <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION IM REPAIR/ADDITION ❑ DESTRUCTION ❑ (No.§eptic system permitte�ublic sewer.is O <br /> - <br /> Installation will serve. Residence__Commercial_ Other •�' <br /> Number of living units:�_ Number of bedrooms \3 r <br /> r <br /> Character of soil to a depth of 3 feet: 1 Water table depth V��F � <br /> SEPTIC TANK 'Qj Type/Mfg Capacity f' ''�No. Compartment, ^. <br /> PKG. TREATMENT PLT. ❑ �T S �1 ethod of Disposal <br /> Distance to nearest: WellFoundation' Pmperty,L-ine_310;P <br /> LEACHING LINE No. & Length of lines AA10 CT` Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> 4 <br /> SEEPAGE PITS ❑ Depth las te 7- -Size !y 5[gf X i0 Number _ 0 <br /> SUMPS Distance to nearest: Well Foundlation ;P7 - Pro — <br /> ` �perty�ine <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and that the work will be dohe in accordance with San Joaquin county ordinances, state laws, and <br /> rules and.regulations of the San Joaquin Local Health District. i <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 applicant must call.for II reqWd inspections. Complete drawing on-reverse side. , <br /> ,Signed X Title: Date: <br /> E <br /> a <br /> ! ! FOR DEPARTMENT'USE ONLY °*A <br /> Application Accepted by _av, <br /> / * - Date �f�� / Area ® � r <br /> Pit or Grout Inspection by Date f' l Final Inspection by Date <br /> Additional Comments: <br /> i <br /> i ❑ Stk 4W-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1, � <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., ox 2009, Stk., CA 95201 <br /> is P.O.,- , <br /> + FEE AMOUNT DUE AMOUNT REMITTED - CK#. , <br /> INFO CASH_ _. `._"RECEIVED BY DATEv PERMIT <br /> + EH 13-24{REV. 10!83) ��" �� IGI� ``• QQ <br /> EH 1128 <br />