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9 APPLICATION FOR PERMIT <br /> SAN JOAQUIN'LOCAL HEALTH DISTRICT <br /> f 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 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 /> '(PA t 0 <br /> I Job Addres� VQ Ko, ? �' City Lot Size PM <br /> Owner's Name 1-?1(y 1 F1 ?-L)a0,VJAddress ttrQ ` 3 3 35- 1 <br /> �e A Phone <br /> I <br /> --Contractor's Name 6k License No. �� , � _ Phone � 3 � <br /> - Y r <br /> r -T°YP_E;OF'WELL/.PUMP_ NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> -'"`PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEARS`SEPTIC TANTO"'!-- — SEWER LINES / DISPOSAL FLD. PROP. LINE <br /> ' - <br /> RCULTUREWELL-FOUNDATION = PITS/SUMPS <br /> �:•, _AR r <br /> INTENDED USE �----MTYPE.OF WELL. I PROBLEM AREA'^CONSTRUCTION.SPECIFICATiONSi <br /> ❑ Industrial Open Bottom l ❑ Manteca Dia. of Weli-Excavation"- - F -'` Li pia. of Well Casing 06 <br /> EI P<DomesticlPrivate 1 C3 Gravel Pack ❑ Tracy Type of Casing S �_`- 5peciadtionsi''' o <br /> ❑ Pudic ❑ Other t 't ❑ Delta Depth of Grodt Seal g `' Ty'pe-of:Grpu^t�"/� f <br /> ❑ Irrigation 1 --Approx. Depth ❑ Eastern Surface SealInstalledby <br /> Repair Work Done.. ❑ Type of Pum H.P. �.� - <br /> i ,.�: � YP p State Work Done <br /> Well <br /> ❑ Well Diameter ` Sealing Material (top 50') <br /> 41 = <br /> 1.T e a �1 Depth A- Filler,aterial (Below 50') <br />[` TYPE OF SEPTIC WORK: NEW INSTALLATION ❑')REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial-_I Other { <br /> Number of living units: Number of bedrooms + 4 <br /> 1. x <br /> Character of sail to a depth of 3 feet: Water table depth <br /> SEPTIC TANK i ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ � Method of Disposal a <br /> Distance to nearest: WN u.—±Q Foundation Property Line <br /> LEACHING LiNC #j ❑ No. & Length of lines `"- Total length/size a <br /> FILTER BED ; 1 ❑ Distance to nearest::- well�p Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size -Number <br /> SUMPS _ d x i❑ Distance to nearest:' Well Foundation Property Line <br /> - _ .. <br /> DISPOSAL POND ❑ <br /> I hereby certify that Lhave prepared this application and that tlie•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. 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."Contractors 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 applica ust rcMI for ail equired inspectl S. Complete drawing on reverse side. ' <br /> Signed Title: Date <br /> • <br /> FOR DEPARTMENT USE ONLY 1 <br /> Application Accepted by * Area o t <br /> Pit rout In pection by Date Final Inspection by Date , <br /> ty - <br /> Additional Comments: <br /> ❑ Stk 466-6761 ` Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE 'I INFO AMOUNT'DUE '�- AMOUNT REMITTED CASH I RECEIVED BY DATE PERMIT-NO.'] <br /> + EH13-241, <br /> EH 101831 -70-0.0 r - --- ,.•-,. ,;,� ........�.pr7,�.y�Q}_ U ��p5 <br /> 1428 <br />