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{EE "� �i•r�9R <br /> APPLICATION FOR PERMIT $ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT - y <br /> D <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES t''YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ';�S.EP 11987 <br /> Application is hereby made to the San Joaquin local Health District for a permit to construct and/oi install the work 0W r Ms t is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and !! rn <br /> Local Health District. <br /> Job Address �. L�� "' ��1 fJ/tlr /3 Vz City�5raG!ifa Lot Size PM <br /> Owner's Name41e) 0 A-51 6'2�41/11 Address C Phone 6e <br /> �NI Nr31flSJ1-�- ,/�� <br /> Contractor /QU�'i9.jO Sri° Address ��- � Ad, JAI+ . `-VA License N �r Phone 46 eT <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR< OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE Q <br /> 5 FOUNDATION'.- = AGRICULTURE-WEL-L -OTHEfi_WELL- -----_P_ITS/SUMPS _r <br /> i, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout <br /> -- <br /> I I Irrigation _--Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done .,Type of Pump J H.P. f l'?� State Work Done 04,D A-It/�, <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.'] REPAIR/ADOITION 1 1 DESTRUCTION I I INo 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 Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ t u Method of Disposal <br /> Distance to nearest: Well Foundation Property Line j <br /> LEACHING LINE ❑ No. & Length of lines Total length/size - <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I'I Depth Size Number <br /> r - - <br /> - SUMPDistance-to nearest:-, i�Well- Foundation Property Line-t-­__-- -4- s4 <br /> DISPOSAL PONDS ❑ r <br /> I 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 owApersoin <br /> ageknc, <br /> rtifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ amme subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies trrformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa-tion lawsThe applictions. Complete drawing on reverse side. <br /> Signed X Title: Ai t/9-a-�.{� Date: <br /> V_ FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection Dat <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> $ Applicant- Return at[ copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 4 , <br /> FEEs - <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 6Y DATE PERMIT NO. <br /> E <br /> + EH 13-24(REV.t!K5) 3 <br /> EH 14-26 "� � ✓ �'! <br />