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I <br /> ' .STM► APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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/of install the work herein described. This application is <br /> F 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 /> k Job Address .3!760 J9 6'-L4 City Lot Size PM <br /> Owner's Name ." Address�� • �.GecC.. �pone <br /> 3 Contractor Address f-!YZ2 c�1 71a(3-16. License No -7-� <br /> La �,��Phone�� <br /> k 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 /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom `❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> j Y,Domestic/Private ❑ Gravel Pack ❑ Tracy -Type of Casing Specifications <br /> r f'i Public ❑ Other FI Delta 'Depth of Grout Seal Type of Grout <br /> I I Irrigation --Approx. Depth"� I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump-4_,&-,/— H.P.5 State Work Done <br /> W Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted if public sewer is <br /> available within 200 feet.i <br /> Installation will serve: Residence_ Commercial_ Other 0 <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: �_? 1Wat`r`table depth <br /> SEPTIC TANK ❑ T e/Mf ( kk� Rd" <br /> Yp 9 Capacity. No. Gaments <br /> PKG. TREATMENT PLT. ❑ � f nMpe�t+hodisposal � <br /> Distance to nearest: Well Foundation, 1Prop16raV90ne <br /> LEACHING LINE ❑ No. & Length of lines "Total Ienjdt ,size! <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line (" ; <br /> r SEEPAGE PITS l I Depth Size _ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that l"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 signafur`e 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 /> f The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X C Title: Date: U-/a <br /> DEPARTMENT USE ONLY <br /> Application Accepted by lo� Date Area <br /> Pit or Grout Inspection by Date Final Inspection by ate 12 rr <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 i <br /> INFO AMOUNT DUE AMOUNT REMITTED" CK f. CASH RECEIVED BY DATE PERM17'NO. <br /> +.EH 13.21 IREV.1 i H 51 <br /> EH 14-2e Y a <br />