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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 's <br /> I (I k . ris <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: Th,is 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 /> 1J'3-2__ �7� -e- (� ` 6' f <br /> Job Address, F <br /> City N Lot Size PM,^ <br /> N _0nev7_-0/ <br /> Owner's Name dress Ph <br /> Contractor Address --License No.—Phone <br /> TYPE OF WELL/PUMP- NEW WELL ED WELL REPLACEMENT L1 DESTRUCTION ❑ <br /> PUMP INSTALLATION Ll SYSTEM REPAIR LJ OTHER El <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 /> C3 Industrial <br /> 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 0 Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> ID Public E3 Other E Delta Depth of Grout Seal Type of Grout <br /> 17 Irrigation ---Approx. Depth C Eastern Surface Seal Installed by Iy <br /> Repair Work Done El Type of Pump F H.P. State Work Done <br /> Well Destruction 0 Well Diameter Seating Material (top 501 <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIR/ADDITION El DESTRUCTION 71Q,(No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> I <br /> Number of living ving units: _...Numbef of bedrooms <br /> Character of soil.to a depth of 3 feet: Water table depth <br /> �9EPTIC TANK' �J Type/Mfg Capacity— No. Compartments <br /> PKG, TRIEAT MENT PLT. CJ. Method of Disposal <br /> AL Distance to nearest: Foundation Property Line <br /> LEACHING LINE El No. & Length of lines i Total le.ngth/siz <br /> FILTER BED 0-Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS D' Depth size Number <br /> SUMPS - Ll -Distance to'nearest: Well-.. ounon FdatiProperty Line <br /> DISPOSAL PONDS 0 1 <br /> ... ................ <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 District. i , i <br /> ot <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'.1aws 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,Iialifornia." 11 1 <br /> The appli must spections. Complete drawing on reverse side.' <br /> Signed Mitt Title: _( { �15 <br /> Date.* <br /> FOR-DEP TMENT USE ONLY <br /> Application Accepted by w Date � Area 1 <br /> Pit or G'rout InsectFonby Final Inspection <br /> by z Date 64—ge <br /> Adpitional Comments: dc <br /> _ <br /> � _;K,Stk 46'6-678-1 ..1 IDLodi 369-3&1'f <br /> , 0 Manteca 823-7104 0 Tracy 835-6385 <br /> Applicant- Return all copieg'to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA SM01 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO RECEIVED BY DATE PERMIT'NO, <br /> + EH 13-24(REV.I/A 5� --W 0C!S7_JAJF er <br /> E 1 12-3 7Vd <br /> H 4-28 1,0"o ND <br />