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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �--� <br /> j 1601 E. HAZEL T ON AVE., STOCKTON, CA . . f <br /> " Telephone (209) 466-6781 <br /> \A1 PERMIT EXPIRES 1YEAR FROM DATE ISSUED N 0 U <br /> (Complete in Triplicate) r,4-i,- � ,� , ��- , �-V, <br /> Application is heieby 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. 1r 1f <br /> Job Address 9 1 �-�� City�_ Lot Size L56 x _53 U PM <br /> Owner's Name PQ U 1��US L� Address 11&, & ac, ryt _n Phone � <br /> Contractor - Address <br /> Q[�f/NE I! Co� V• 190kd en License No. 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 /> 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 V j <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> FI Public ❑ Other n Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation _.Approx. Depth 11 Eastern Surface Seal Installed by <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 <br /> TYPE OF SEPTIC WORK: NEW INSTAL TION I l REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is <br /> ava�labl within 200 feet.) ''�(�� <br /> Installation will serve: Residence Commercial Other 4Q_ _ <br /> Number of living units: Number of bedrooms_ <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK X Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> 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 /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation 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, and <br /> rules and regulations of the San Joaquin Local Health Diltrict. <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 applic mu call for all requir d inspec'ons Complete drawing on reverse side. <br /> Signed X_ J J Title: �C��C ! Date: <br /> t- DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by / Date Final Inspection by <br /> s � <br /> Additional Comments: —/ -7 <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 <br /> INFO MOUNT DUE AMOUNT REMITTED C SH RECEIVED 8; DATE PERMIT NO. <br /> a.EH13.24(REV.I H 5) 2�,�q ��� F ` / ? JVF-57J> <br /> EH 14.26 s� V ✓✓✓JJJ J t i <br />