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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAC''HEALTH DISTRICT <br /> 1601 E. HAZELFON AVE,, STOCKTON, CA PC& <br /> Telephone (209) 466-6781 <br /> {k PERMIT EXP (Complete <br /> FROM DATE ISSUED JO� <br /> Compl to n TIipI6p©S7T�L@c,�® • • <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descri6� loplication is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1962 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. At <br /> Job Address ` -5 City . . Lot SizePM <br /> Owners Name � ✓ � Address dus� , ��"w^- + �^t'^� Phone -2^� <br /> Contractor's Name ���""" +cense No. /�� 3 7 Phone Z <br /> TYPE OF WELL/PUMP: NEW WELL ❑ <WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> if <br /> PUMP INSTALLATION" ❑ SYSTEM REPAIR R'' OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD. PROP. LINE <br /> _ FOUNDATION F AGRICULTURE WELL OTHER WELL; PITS/SUMPS <br /> INTENDED USE TYPE OF WELL .PROBLEM AREA CONSTRUCTION SPECIFICATIONS - v <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation ! r Dia. of Well Casing <br /> \; <br /> Domestic/Private ❑ Gravel Pa4kTracy Type of Casing ! SpecNcations ' <br /> ❑ Public ❑ Others rp Delta Depth of Grout Seal I ' �+ Type of Grout <br /> I <br /> ❑ Irrigation Approxi Depth [O Eastern Surface Seal Installed by <br /> , Repair Work Done fd� Type of Pump Qw�,,e H • P, State Workbcne . <br /> Well Destruction LI Well Diameter ty Sealing Materia! Itop 50'1 <br /> Depth � " " Filler Material ( Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION .❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> �...,. . a 111e� / available within 200 feet.) <br /> \ <br /> InstallationwrlLsenre= Residence — Commercial __ Other <br /> Number of living units: t Number of bedtooms ^ l _�•_. ``t .,- • ^ w. <br /> Character of soil to a depth of 3 feet:! ) - i ^ !,,Water table depth <br /> SEPTIC TANK ❑ Type/Mfg f Capacity" ^• No. Compartments <br /> PKG. TREATMENT PLT. ❑ ,;p 1 % �r Method of Disposal <br /> Distance to nearest. Well Foundation § t� Properly Line <br /> Y <br /> LEACHING LINE 171 No. & Length of tin' s 1 Tata! length/eiz <br /> A <br /> FILTER BED ❑ Distance to nearest' Well Foundation Property Line <br /> i i ( k.. <br /> SEEPAGE PITS ❑ Depth Size • i ! ' Number <br /> SUMPS ❑ Distance to nearest: Well Foundation; Prope`ity Line <br /> DISPOSAL"PONDS ". El 'i' " `r i .• 0 - _ _ _ <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state fawn, and <br /> rules and regulations of the San Joaquin Local Health District. it I . <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." Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is.issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California:' ' > it �x <br /> The applicant t cel for all quired inspeotl s. Compleyte d�rawingo�nyr�ev�erse side. Jr fr <br /> Signed 1C r s"r�Title: � � Date: <br /> - / FOR DEPARTMENT USE ONLY S <br /> Application Accepted by `N � 7/ Date • Area A <br /> Pit or Grout Inspection by f Date Y Final Inspection by Oawa 2 ; C) XS <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑ Lodi 36.93621 ❑ Manteca 823-7104 `f%� ❑ Tracy 835.63% <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1606EzwHazeltan Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEINFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE <br /> pPERMIT-NN0.. - <br /> + EH W41REY. 10/631 ('"tJ D S �� �D7 '+ <br />;i EH 1d-te - <br />�� 1 <br />