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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> t� 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 /> Job Address z�d�` Lde moi, ��'Z�1 City Al"A JT,ECrP Lot Size li!24 KILL- .1 PM <br /> Owner's Name C'n c21C 11; , Aocc d,4 Address .S'i��J. Phone <br /> Contractor's Name 42AXXSSH "1 jSNS License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM M OTHER 11DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES C AL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OT_AR WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIOfYS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatio Dia.Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing '' Specifications <br /> _ <br /> ❑ — <br /> -Public � Other Delta -6eptfi o­f-Groui$eT—"-- Type of Grout Q ` <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by 1w <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material-(Belo 501 (' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION IV DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_Z Commercial_ Other <br /> - ti= <br /> Number of living units: I/-- Number of bedrooms _S / <br /> Character of soiF to a depth of 3 feet: .14,440y - - Water table depth -- «--- <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments a <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of lines r p Tial length/size <br /> FILTER BED ❑ Distance to nearest: Well <br /> ndation Property-Line _ <br /> Z wzd <br /> SEEPAGE PITS ❑ 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 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 all for all required inspections. Complete drawing on reverseide. <br /> Signed X Title: * Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 22 Area <br /> Pit or Grout InspectioDate Final Inspection by 1-1 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 <br /> INFO f •AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> + EH 13-24(REV.10/83) <br /> EH 1428 111 S <br />