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APPLICATION FOR PERMIT 15—sSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �j 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> !� Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' <br /> (Complete in Triplicate) °� y <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install theworkherein 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 Yala. Me 13readw-IdIVCity Lot Size PM <br /> i exw n <br /> Owner's Name JWC1_�':,_�a_ t� lML,&rY dress Phone <br /> Contractor LJ �/ �� Address License No, w-- Phone <br /> �.�. <br /> TYPE OF WELL/PUMP: ? NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PLIMAAUZ16LLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL HER,WELL PITS/SUMPS <br /> INTENDED USE :TYPE OF WELL PROBLEM AREA CIFICATI <br /> ❑ Industrial ❑ Open Bottom ca Dia. of Well Excavation of Well Casing 2 <br /> ❑ Domestic/Private ElGravel ❑ Tracy Type of Casing Specificatl � <br /> FI l Public ter 171 Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation Approx, Depth l I Eastern Surface Seal Installed by _ <br /> — 4 <br /> Repair Done ❑ Type of Pump H.P. State Work Done_ <br /> I Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: 1NEW INSTALLATION f-I REPAIR/ADDITIONS I DESTRUCTIONV; INo septic system permitted if public sewer is ! <br /> Installation will serve: Residence_ Commercial_ Other <br /> i available within 200 feet) <br /> Number of living units: 1 Number of bedrooms j <br /> Character of soil to a depth of 3 feet: Water table depth k <br /> SEPTIC TANK X Type/Mfg `Capacity x No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> } <br /> LEACHING LINE ' ❑ No. & Length-of-lines— -- Total length/size <br /> FILTER BED ❑, Distance to nearest: Well Foundation 1 Property Line <br /> SEEPAGE PITS Depth Size Number <br /> 1. <br /> SUMPS L Distance to nearest: Well i Foundation 1 Property Line <br /> DISPOSAL PONDS ❑. <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, <br /> rules and regulations of the San Joaquin Ltical Health District. f <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." r <br /> f <br /> The applicant must tali for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: 'Sp iy m yal r _ Date: i r <br /> I £ FOR DEPARTMENT USE ONLY <br /> Application Accepted by " �'� `w`"'� Date v Area ©� <br /> t t � <br /> Pit or Grout Inspection by (�'[ '_Date f _/ _ 4i al Inspe�n by Date <br /> Additional Comments: Jct s7 �/ A S <br /> C1 5tk 466-6781 ❑ Lodi f69-3621 Manteca 823-7104 ❑ Tracy 835-6385 i <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O`. Box 2009, Stk., CA 9525 01 <br /> VIF <br /> INFOFEE MOUNT P, - AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> -.Ae.1", <br /> C/W <br /> + EH 13-24AREV,t i n S1 _ ,—,3S—C70 V <br /> ✓✓✓ /V VV _Y <br /> EH 14-28 � � 77 <br /> i <br />