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r <br /> APPLICATION FOR PERMIT <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 /> 3 16 <br /> Job Address 0 City Lot Size <br /> �a0l�IScS PM <br /> Owner's Name 1\Q_cJ� r �4��hMddress -9a�'f— Phone 31—1TO <br /> Cd S.&L4W 4Wet` I Address FO 84JCIS305 115a0- License No. Alai' Phone ? T S 6 <br /> TYPE OF WELL/PUMP: .�> NEW-WELL K WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <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 f <br />` ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatio /Q pia. of Well Casing <br /> PL Domestic/Private >e Gravel Pack C1 Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other F1 Delta Depth of Grout Seal w Type of Grout _ <br /> 1 1 Irrigation _._Approx.IDepth { I Eastern Surface Seal Installed by A 4 _ <br /> Repair Work Done ❑ Type of Pump H.P. State ork Done <br /> Well Destruction ❑ Well Diameter Sealing'Material (top 50') <br /> Depth a! "� Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ DDITION I I DE RUCTION I I (-No septic system permitted if public sewer is O <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Othe <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 TZ <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance.to nearest: Well Fou dation Property Line <br /> 4 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundati Property Line <br /> SEEPAGE PITS I I Depth N Number <br /> SUMPS ❑ Distance to nearest: ell Foundation Property Line <br /> I DISPOSAL PONDS ❑ <br /> I hereby certify that t 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 Di§trict. <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." <br /> The applicant t call for all quirao inspections. Complete drawing on reverse side. 7y' <br /> Signed Title: a � � Date: _ / !��� <br /> R PARTMENT USE ONLY <br /> Application Accepted by � ✓ Date -0 Area <br /> Pit or Grout Inspectionby /- lJ Date 7 Z Final Inspection by <br /> Additional Comments: f dV 1 IJJ �l,/�. s,Sr� Date <br /> C 6 —1 7 GI <br /> li ❑ 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 INFO AMOUNT UE t AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> +.EH 1324 I �Jt i�p 51 /� r <br /> EH 14-28 #STtr7'+ ^ ��-9 "143— <br /> w all $ Y i - qO - 1-75y a <br /> .4u Pu L&a it <br />