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li <br /> i� APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Teiephone (209) 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> ii (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 /> r ib' <br /> Job Address Y Cit STi�'� SoX/,Zo <br /> Lot Size PM <br /> Owner's Name Address Sri <br /> 1 Phone <br />{ Contractor FG /� La`c'y-Z� �Address <br /> License No. rr�-7d Phone_144 33'� <br /> TYPE OF WELL/PUMP; i NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SFPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TE OF WELL OBLEM AREAP~CONSTRITCTION-S-P'E&ICATIONS <br /> ❑ TYPE <br /> Industrial ❑ Open Battom `Q Manteca Dia. of Well"Excavation <br /> 0 Domestic/Private ❑ Gravel Pack Dia. of Well Casing <br /> ❑ Tracy ' '. Type of Casing <br /> I1 Public ll Other '"'' + Specifications <br /> 17 Delta _Depth of Grout Seal <br /> I I Irrigation q d Type of Grout _ <br /> ., pprox. Depth I I EasternSurface Seal Installed by <br /> Repair Work Done El Type"of Pump �'H p ' <br /> Well Destruction ❑ Wellbiameter State Work Done w <br /> Sealing Material (top 50T <br /> Depth sFiller Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I:] REPAIR/ADDITION DESTRUCTION I 1 (NO septic system permitted if public sewer is <br /> Installation will serve: Residence Commercial available within 200 feet.) <br /> � ��� Other + <br /> Number of livingunits: + <br /> !~' Number of bedr`oomsN' i <br /> Character of soil to a depth of 3 feet: L i Q <br /> SEPTIC TANK " Water table depth <br /> ❑ Type/Mfg <br /> PKG. TREATMENT PLT. ElCapacity No. Compartments <br /> r <br /> Method of Disposal <br /> Distance to nearest: Well Foundation � ' <br /> Property.Line 1'" <br /> LEACHING LINENo. & Length of lines O + , <br /> FILTER BED Total length/size f <br /> ❑ Distance to nearest: Well - -''o . r <br /> Foundation <br /> ---�s�_:� Property Line <br /> SEEPAGE PITS 11 De th <br /> p Size— <br /> SUMPS F+_ / Number. J� <br /> ' Distance to nearest: + Well -, <br /> Property <br /> DISPOSAL PONDS ❑ } + - +z�— .Foundation_"`.__, ' Pro Line <br /> p <br /> I hereby certify that I have prepared.this application and that the Work will be done inwa'ccordance with San Joaquin county-ordinances, state laws, add- <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 <br /> employ any person in such manner as to become subject to'-workman's compensation lawsofPerformanceof <br /> Contractor's work for rchtHis hiring arpermit is sub-contractingfsignaltv�� <br /> certifies the following:."I certify`,that in the performance of the work for which this permit is issued, !shall employ persons subject to workman's compensa- <br /> tion laws of Californian"+ il <br /> The applicant must call for all required inspections. Co'plate drawing on reverse side. <br /> Signed X ! t <br /> Title: <br /> A <br /> Date: <br /> IR F DEPARTMENT USE ONLY <br /> Application Accepted by Q k <br /> Date l Area <br /> Pit or Grout Inspection by I <br /> Date Final Inspection by <br /> IF Date�_• <br /> Additional Comments: <br /> ❑ Stk ,:466-6781 ❑ Lodi 369-3621 p'fUlBntecs`�823=7f04"'° �❑ Tracy 8356385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA ga201 <br /> ,J <br /> � t f <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO RECEIVED BY DATE PERMIT'NO. <br /> +.EH 13-21(REV. <br /> EH 11-28 0 <br />