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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL 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 /> Y ,C11��l�'�S - PM�a <br /> Job Address City Fsl^��,an l -'Lot Size <br /> Owner's Name ! Address ��j9 3D Su:a I t 7 - Phone <br /> 3g <br /> Contractor's Name ZV mig aA. icense No. .-?)ko 5-1 — Phone �3 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION <br /> �y� SYSTEM REPAIR 71 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES �CJ/Z DISPOSAL FLD.&)Q Y PROP. LINE <br /> FOUNDATION . /5'1- AGRICULTURE WELL OTHER WELL(Q_- PITS/SUMPS IAD�- <br /> 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 szgkGravel Pack ❑ Tracy Type of,'Casing iS 70f­ - Specifications <br /> ❑ Public [1 Other ❑ Delta Depth of Grout Seal 50 Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. r State Work Dane <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50')," <br /> Depth W Filler Material-(8_elo_w 50') <br /> TYPE OF SEPTIC WORK.: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is J <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 �r <br /> PKG. TREATMENT PLT. ❑ Method of Disposal �V <br /> Distance to ne3`rest:, IW6111 —` Foundation Property Line rt= <br /> r <br /> LEACHING LINE ❑ No. & Lengthlof lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property'Line <br /> SEEPAGE PITS ❑ Depth Size Number y <br /> r" <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl <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 /> II 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 campensai <br /> tion laws of California." <br /> The appli must cal for all required inspections. Complete drawing on reverse side. <br /> 5 a- Q <br /> Signed <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by \v Area <br /> Pit or Grout Inspection bg­6:f�-- <br /> pate � Fina! Inspection by Date 3 <br /> Additional Comments: <br /> ❑ Stk 4664M1 ❑ Lodi 369-3821 Xj,'hAanteca 823-7104 ❑ Tracy 835-6385, <br /> Applicant Return all copies to: Environmental He lth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,.Stk., CA 95201 <br /> AMOUNT DUE <br /> FEE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. <br /> . s <br /> � INFO <br /> +EH 13-24(REV.101891 17S-C. -zs"i a -e <br /> [ EH 14-28 <br />