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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) 456-6781 <br /> I <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. ,r <br /> c) 0 } Qom <br /> Job Addres - ` 1 �Q `- .= 3 Cit), a' Et'. ` Lot Size PM <br /> Owner's Name QNS-Address - Phone <br /> Contra t ' �U �% ress , � p <br /> `- Icense No. L9 Q. Phone i 7 <br /> --?( <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ TRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE " <br /> FOUNDATION " i AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE r-TYPE-or-WECC-—PROBLEM AREA--*CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial r❑ Open Bottom CO Manteca"-' Dia. of Well Excavationt <br /> Dia. of Well Casing <br /> ❑ Domestic/Private !,❑ Gravel.Pack ° <br /> -rl ❑'Tracy; Typo of Casing Specifications �� P <br /> ❑ Public-, =❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> rrigation I—Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of P,` H.��-! H.P. State Work Done <br /> Well Destruction ❑ Weil Diameter Sealing Material (top 50') } <br /> Depth r <br /> p Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ fNo septic system permitted if public'sewer is <br /> available within 200 feet.) <br /> I <br /> Installation will serve: Residence_ Commercial— Other I :O <br /> i Number of living units:F"""-'""'Number of,bedrooms " <br /> Character of soil to a depth of 3 feet: <br /> _ Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity_ . (' o. Compartments - <br /> .._ _) # <br /> PKG. TREATMENT PLT. 71 <br /> Methodof Disposal) <br /> r <br /> Distance to nearest; Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of linesTotal length/size 1 y #!. <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 ❑ <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 (3 <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 be me ject to workman's compensation laws of California."Contractors hiring or sub-contracting signature r <br /> certifies the fo wing:"I certify that' theertor once of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of ifornia." <br /> The applic t ust all I r g d i specti n'. Complete drawing o v side. <br /> Signed C; <br /> Title: Da 2r L <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted b Date Area Gl <br /> Pit or Grout Inspection y Date p Final Inspection by Date 7 <br /> Additional Comments: f ,Ar"�j� Wa wj <br /> ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy <br /> Applicant- Return-ail-co---io:-£nvironmental Health-Permit/Servic:es,1601-E."Hazelton Ave:, P.0"Boi'2009,'Stk:, CA•95201 C� Tr Y/vj <br /> —INFO FEE ""AMOUNT DUE,. —AMOUNT-REMITTED—REMlTTED�.� ,+CASH""? RECEIVED,BY;:.� _.;_w; DATE, _ .PERMIT=NO. w <br /> + EH124fREV.F/a51 <br /> EH 144-28 cZC ! b 7 S7�-7I , <br /> ��JJ �J <br /> - s <br />