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APPLICATION FOR PERMIT toe Ir �e!'•�. `' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466_8781 <br /> PERMIT EXPIRES 7 YEAR FROM .DATE ISSUED <br /> I r.(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 /> 41 q:y <br /> Joh Address '67 �cT Li h f -J -7,1 Ci 9 iP C/ 5. <br /> I PM <br /> Owner's Name r,aPle, <br /> a Address G CJS i74r-AWt - Phone 9'✓SSS���3 <br /> �� I <br /> Contractor's Name Pe cl/,�$ IVA - �� <br /> License No. r Phone <br /> TYPE OF WELL/PUMP; NEW WELL'% WELL REPLACEMENT El DESTRUCTION ❑ <br /> PUMP INSTALLATION [ � SYSTEM REPAIR ElOTHER ❑ ' <br /> DISTANCE TO NEAREST: SEPTIC TANK b SEWER LINES DISPOSAL FLD. PROP. LINE <br /> _ -FOUNDATlON;:— AGRICUL=TURE:WELL4=--_--OTHER-WELL -� PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> 'Domestic/Private Gravel Pack ❑ Dia. of Well CasingTracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal <br /> f] Irrigation Type of Grout <br /> 1 pprox. Dept �❑ Eastern Surface Seal Installed by <br /> ED Work Done Type of Pump H.P. SE State Work Done T17 S?,a ✓1.1 Jr <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material {top SO'} <br /> Depth �-�i d �. Filler Material (Below 50,1) <br /> TYPE OF SEPTIC WORK: NEW INSTAL <br /> LTION 1!11 REPAIR/ADDITION EDDESTRUCTION ❑ (No septic system permitted if public sewer is # <br /> V1 <br /> Installation will serve: Residence� .Commercial i, Other available within 200 feet.) <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. ❑ <br /> Method of Disposal f <br /> Distance to nearest: Well FoundationProperty Line <br /> ` I � <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line Q <br /> SEEPAGE PITS ❑ Depth Size Number <br /> ED—Distance to_nearest:,- _Well: _ F_oundation- <br /> DISPOSAL PONDS ❑ RP_roperty_Line. <br /> 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 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 app/' t ust call for all re d 'ns ion omplete drawing on everse side. <br /> 4 <br /> Signed,.� eVIP <br /> `err Title: ' ` - Dater <br /> DEPARTMENT USE ONLY <br /> Applicatio Accepted Dat MA?196' 6 <br /> w A f Area <br /> Pit ar:=Grout Inspectio y !V Date Final Inspection by �r- <br /> Date <br /> Additional:Comments: f' ' <br /> ❑ Stk-„4@8-6761 _D Loi d! 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 AMOUNT DUE { AMOUNT REMITTED <br /> INFO I ERECEIVED BY DATE PERMIT"NO, <br /> + EH 13-24(REV.10/83) `'EH 1x26 IL.IS`i <br />