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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES I'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is heieby 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. 11862 for well/purnp and the Rules and Regulations of the San Joaquin <br /> Local Health District, <br /> Job Address 1�57 City Lot Size PM <br /> Owner's Name &14,Zl Address Phone <br /> Contract Addres.Z5_3� Z, License 4s��_Phon <br /> Vv1=LL REPLACEMENT 0 DESTRUCTION 0 <br /> TYPE OF WELL/PIJIVIP� NEW WELL Ll <br /> PUMP INSTALLATION 171 SYSTEM REPAIR 0 OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLO.— PROP. LINE <br /> FOUNDATION AGRICULTURE WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEIVJ_&&�C07NSTRUCTION SPECIFICATIONS <br /> 11 Industrial EI Open Bottorm�h �anteca Dia. of Well Excavation Dia. of Well Casing <br /> �,W �._ , <br /> _ __C3 Tracy <br /> 0 Domestic-/Private El Gravel 0 Tracy Type of Casing Specifications <br /> ,P <br /> [-I Public E� Delta Depth of Grout Seal Type of Grout <br /> PIP —bepth � I Eastern" Surface Seal Installed by <br /> 1 1 laigation _A r.x. <br /> Repair one 0 Type of Pump �H.P. State Work Done <br /> Destruction ED Well Diameter Sealing Material Itop 501 <br /> Depth__­_- Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.I REPAIR/ADDITION 1.1 DESTRUCTIO&Iot*o septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will servo: Residence - 'Commercial %Other: <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: —Water table depth <br /> SEPTIC TANK El T�pe/Mfq Capacity— No. Compartments <br /> PKG. TREATMENT PLT, 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED El Distance tonearest: Well Foundation— Property Line <br /> SEEPAGE PITS I Depth Size Number <br /> SUMPS L1 Distance to nearest� Well Foundation Property Line <br /> DISPOSAL PONDS 0 . <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, st.ate laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signalu re certifies the following: "I certify that i n.the performa nce 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 I' t t all for all required inspections. Complete drawing on reverse side. <br /> C-.' �e A- l('7. <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> -7 <br /> by aQ th,4�66 L79%j I Area <br /> Application Accepted Date <br /> Pit or Grout Inspection by Date Final Inspection by Dat <br /> Additional Comments: <br /> 0 Stk 466-6781 El Lodi 369-3621 0 MaWca a23-71134 0 Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2DD9, Stk., CA 95201 <br /> FEE AM UNT DUE AMOUNT REMITTED CK 'NO. <br /> INFO H RECEIVED BY DATE PERMIT <br /> `-614 I-S-1 <br /> + EH 13-24 IFIEV,I/R 5) <br /> EH 14-26 <br />