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APPLICATION FOR PERMIT ff <br /> FC <br /> SAN JOAQUIN':LOCAL HEALTH DISTRICT <br /> ` 1601 E. T ON AVE., STOCKTONCA A.- <br /> F HAZEL , <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/ r s the work described,This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1852 for well/pump and the Rules andRegulations of the San Joaquin <br /> Local Health District. J <br /> Job Address 3­1 —f7 e C "r a O Y1 <br /> ,^� IS� Ave� City S�1�1v� Lot Size PM <br /> Owner's Name )Zs, C V L C '}f I Address Z L���) <br /> 1f Phone 1C15'Z--- A/0-7Contractor's Name �- I-1Z Ar( pin� License No. ` 3 3 Phoneb <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 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 ff Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack! ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other I ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation _._ Approx. 5epth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done Wp <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 \�`1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION C1REPAIR/ADDITION• .. DESTRUCTION 01 <br /> (No septic system permitted if public sewer is \ <br /> available within 200 feet.) <br /> Installation will serve: 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 ❑ Type/Mfg r _ Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size _ <br /> FILTER BED ❑ Distance to nearest: Well 'Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS - ❑ Distance to nearest. " Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I <br /> k <br /> hereby certify that f have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stat <br /> rules and regulations of the San Joaquin Local Health District., e laws, and o <br /> Home owner or licensed agent's signature certifies the following; "I certify that in the performance of the work for which this r <br /> employ an permit is issued, I shall not <br /> P Y y person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature u <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 <br /> The applicant m t c Il for all required inspections. Complete drawing on raver side. <br /> Signed 4. � Title: 4 — `"- �. <br /> Date: L <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by AM Date `31 Area C0 <br /> Pit or Grout Inspection by Datet- „� Final Inspection by Date <br /> Additional Comments <br /> ❑ Stk 466-6781 ❑ Lodi 369 362 , ❑ Ma ca 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 AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH13-24 fREV.t0/931 ' <br /> EH 1426 <br />