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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT' y � <br /> HAZ I' <br /> 1601 E. HAZELTON ON AVE.; STOCKTON, CA � � <br /> Telephone (209) 466.6781 No Wcz I OW firy <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED N�.tip{�,L� /� N, � <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 here described. his 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 + J3 QST <br /> City `Lot Size -57p G a PM <br /> Owner's Nam 2D0 <br /> �- ,Addres° �dtir'�' Lh �.eta .1101^1. 01 Phone <br /> • �` t.ar c.[Xe <br /> Contractor Address ' <br /> TYPE OF WELL/PUMP: License No. Phone <br /> NEW WELL EJWELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER EDI <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL <br /> OTHER WELL PITS/SUMPS ( y <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �V <br /> ❑ industrial "x <br /> ❑ Open Bottom ❑ Manteca tDiP'of Well Excavation <br /> 1:1Domestic/Private ❑ Gravel Pack Dia. of Well Casing <br /> ❑ Tracy Type of Casing <br /> Specifications <br /> ❑ Public ❑ Other ❑ Delta <br /> Depth of Grout Seal Type of Grout I <br /> ❑ irrigation __ Approx. Depth L.1 Eastern S j <br /> �a e Seal installed by <br /> Repair Work Done ❑ Type of Pump H.P. <br /> Well Destruction ❑ Well Diameter State Work Done <br /> w SealingrMaterial {top 50') t <br /> Depth Filler Material(Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO <br /> I iNo septic system permitted if public sewer is <br /> Installation will serve: Residence -� Commercial on Other <br /> ' r. 4w available within 200 feet.I <br /> Number of living units: _L Number of bedrooms <br /> Character of sol to a depth of 3 feet: ' <br /> SEPTIC TANK Water table depth <br /> ❑ Type/Mfg CapacityNo. Compartments <br /> PKG, TREATMENT PLT. ❑ � <br /> Distance to nearest: Well <br /> Method of Disposal <br /> Foundation <br /> . Property Line <br /> LEACHING LINE 1 No. & Length of lines <br /> Total length/size <br /> FILTER BED <br /> ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> rt <br /> SEEPAGE PITS ❑ Depth Size <br /> SUMPSNumber <br /> ❑, Distance to nearest: Well Foundation <br /> DISPOSAL PONDS El Property Line ` <br /> 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, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following:"I ce 'y hat in the performance of the work for which this permit is issued, I shall employ <br /> tion laws of Calif r_ia." p p y persons subject to workman's compensa- <br /> tion <br /> applicant c II f I required inspections. Complete drawing on reverse side. <br /> Signed <br /> Title: _S <br /> Date: <br /> y FO TMENT USE ONLY q� <br /> Application Accepted b.y w`vt� Date v D <br /> A►ea <br /> Pit or Grout Inspection by Date <br /> Final Inspection by Date �� <br /> Additional Comments: 17/ <br /> ED 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,,, AMOUNT DUE AMOUNT REMITTED RECEIVED BY <br /> DATE PERMIT'No. <br /> t' <br /> + EH 13-24(A EV.1i95) J l <br /> FH 14-26 3 O <br /> ,�.. -7 �� <br />