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APPLICATION FOR PERMIT is P, <br /> ., SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1-YEAR, FROM DATE ISSUED <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. 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 /> Job Address ff/+ City Lot Size PM <br /> Owner's Name Address 11 2— YO 4 11,14+i`a Ill Phone /61/ <br /> .Contractor "­ddress' . 2 :3/V h—,C-.7— License Wo{` PhoneF 7 <br /> TYPE OF WELL/PUMP: V NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> f t PUMP INSTALLATION ❑ SYSTEM REP ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER NES e DISPOSAL FLD. PROP. LINE ' <br /> { FOUNDATION AGRICUL URE LL OTHER WELL PITS/SUMPS <br /> r,- <br /> INTENDED USE ""_%TYPE OF WELL PROBLEM AREA NSTRUCTION SPECIFICATI' <br /> ❑ Industrial El-Open-Bottom-13 Manteca -�-- •Dia. of WeII.Excavation Dia. of Well Casing <br /> ❑ Domestic/Private. ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F1 Public �i'"Fl Other Cl Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation _.Approx. Depth I l Easte P Surface Seal Installed by _ <br /> Repair Work Done'0?7'Typo of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter - -' :Sealing Material {top 50'1 <br /> i 'Depth Fill er.Materia! (Belo50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION IK DESTRUCTION I I INo septic system permitted if public sewer is �- <br /> available within fee 1 <br /> Installation will serve: Residence Commercial_ Other j z U,� <br /> Number of living units: A <br /> .1 Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK - ❑ Type/Mfg CapacityNo. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disp sal <br /> "Distance10 nearest: Well rte!-Foundation Pro erty-Line <br /> A p t <br /> LEACHING LINE ! Cl' No. & Length df of s74 AD frotqL4en,gth/size <br /> FILTER BED ❑ Distance to near a ndatio y Line <br /> SEEPAGE PITS j,sJ 4 i.1 Depth '� Siz Number <br /> SUMPS fF` Ll;' Distance to nearesaw , <br /> ndati partyLine <br /> DISPOSALPONDS ❑ o <br /> I hereby certify thatJ.have prepared this application and that the work will be done in accordance with Sarnoaquin 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." 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." % I "_t <br /> The applicant`* ust call for all required inspections: Complete drawing on reverse side. '# <br /> Signed X '� � Title* Date: , <br /> F ' FOR DEPARTMENT USE ONLYZf <br /> Application Accepted by Date o` Area <br /> Pit or Grout Inspection by ' '.Date -?f Final Inspection by Date <br /> Additional Comments: ^ 0 c a_44— J u I'� 1 C V _PL `� ` ` '�r� 7 <br /> 4L] SW 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmgntal Health Perm' /Services L401 E. Hazelton Ave., P. Bo 2009, Stk., CA 95201 <br /> I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> l <br /> 60 <br /> +.EH13-241RtV.siNrI <br /> EH 14-2e f <br /> d <br />