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it -1-14,- Sall l.�cl�,�.g <br /> G�ruvr`� tuk,�r ur_G+, .�wk d- � S-�✓�L� c -� <br /> r APPLICATION FOR PERMIT �' ^`°}��r pu� -ed�rU <br /> 11_Z-Y-� Calc..,d k.r.-.lam-d�.�.c..j �v_ +0 cuv,rei- G7 !1-Zu44, <br /> v� ,�e� rJuw• r'��" °. SAN JOAQUINiLOCAL HEALTH DISTRICT <br /> fG�eJ Gov✓ct.{.-sir 1^�C�d�e Zr-Y�+ Y '�Lt <br /> I k 4 �{G✓y UU h 1601 E. HAZELTON AVE., STOCKTON, CA ti"° °"r L,}tJ <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ��� <br /> (Complete in Triplicate)' lei <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 <br /> �Ld r City Lot Size �"Q' PM <br /> Address t a- t .i-c - Phone 3 O O <br /> Owner's Name . - �/ r f <br /> Contractor's Na License No. J4 ji6;?16 Phone 3 <br /> TYPE OF WEL ' U_MP: 1 NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION*❑. SYSTEM REPAIR td' _ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -'DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE { PE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial Ope n Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing J <br /> ❑ Domestic/Private ❑pGravel Pack kms.,...D=Tracy Type of Casing Specifications <br /> G',Public ❑O�er' LE.I-talrn <br /> Depth of Grout Seal Type of Grout <br /> 131 rrigation pf[' Approx. D. h Surface Seal Installed by OQ <br /> &Repair Work Done ❑ Type of Pump H.P. ZR? State Work Done ({} <br /> /� <br /> ,Well Destruction © Well Diameter ---fid+=— Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> +s i k� available within 200 feet.) <br /> Installation will serve: ' Residence— Commercial_ Other [A <br /> Number of living units Number of bedrooms l <br /> I""" -- Water table depth <br /> � Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> i 'Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> (� I <br /> J SEEPAGE PITS ❑ Depth Size -Number <br /> /SUMPS 1-1Distanceto nearest: Well Foundation Property Line <br /> /DISPOSAL PONDS ❑ d <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 applicant must all f r all a fired inspections. Complete drawing on reverse side. l <br /> , P %1 F- <br /> Signed �" Title: Date: <br /> FOR DEPARTMENT USE ONLY r—� Cl,A 6 <br /> Application Accepted by Data Area--' /i <br /> Pit or Grout Inspection by Date Final Inspection by 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 CASH RECEIVED BY DATE PERMIT`NO. <br /> INFO <br /> + EH 13-24[REV.101811 12 <br /> EH 1426 <br />