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'I APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> I� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I! (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. i <br /> Job Address ee^ ►V City'Y�� Lot Size/Old . Ml PM <br /> Owner's Name 1Z14W ,� P1 I'd Address Iy Phone <br /> Contractor 'I Address /1N'Q1 License No. Phone <br /> TYPE OF WELL/PUMP: ii NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SY,STEM REPAIOTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES " - a 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 <br /> ❑ Domestic/Private ❑ Gravel Pack ❑,Tracy Type of Casing Specifications 1 <br /> f"1 Public n Other a <br /> ' �. Cl'belta r Depth of Grout Seal Type of Grout r <br /> I 1 Irrigation �'?Approx. Depth. 'I I Eastern Surface Seal Installed by ! <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well`Diameter Sealing Material Itop 50') n <br /> Depth Filler Material (Below 50') h <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i;l REPAIR/ADDITION l I DESTRUCTION i I Wo septic system permitted if public sewer is <br /> R I! available within 200 feet.) <br /> Installatio ill serve: Residence _ Commercial_ Other <br /> Number of livin nits: Number of bedrooms <br /> Character of soil to a th of 3 feet: Water table depth <br /> SEPTIC TANK ❑ pe/Mfg clay No. Compartments <br /> PKG. TREATMENT PLT. ❑ i. Method of Disposal <br /> Distance Well "Foundation Property,Line <br /> ii <br /> LEACHING LI C1 No. & Length of line Total length/size ' <br /> FILTE ED ❑ Distance to nearest: ! Foundation Property Line ! <br /> s <br /> �1 <br /> SEEPAGE PITS ti Depth Size Number <br /> SUMPS 0 Distance to nearest: Well dation 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 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, !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 must call for all required inspections. Complete drawing on reverse side. <br /> Signed Title:— �"� Date: 14;> <br /> FOR DEPARTMENT USE ONLY [' <br /> Application Accepted byQADate 9'f Area J <br /> Pit or Grout Inspection,bsy� Date Final Inspection by �i Date <br /> 1. <br /> Additional Comments: ` -k- 6✓". P4-V G.�` �- ��^ Z r�LL� uV t ,u �` r��f b <br /> f <br /> 1) Stk 466-6781 El Lodi it lig 3621 ❑ Manteca 823 7104 ❑ Tracy 835-6385 0 PV tn,ZY '�T <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601•E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> CLFEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. Itf <br /> ♦.EH13-241REV.a/H51 i <br /> 3 :5,00 <br /> r7ay `7So �4. <br /> EH 14.26 <br /> 'i <br />