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h APPLICATION FOR PERMIT I, �'Ll <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT f•Cj IL!! <br /> 1601 E. HAZELTON AVE-, STOCKTON. CA,,�f_ - ©EC G � 7 <br /> Telephone (209)466-6781 <br /> s !PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIROMENTAL HEALTH <br /> (Complete in Triplicate? FERMIT/SERV <br /> :p dascdhed.Thies <br /> Application is hereby made to the San Is <br /> Jdaquin Local Heahh District for a permk ro cof!struat and/or install the work frerekr <br /> made <br /> Apin plication <br /> with San Joaquin . onty Ordinance No.548 for sewage or No. 1882 for wall/pump and the Rules and Regulations of the Sen Joaquin <br /> p. <br /> Local Health D-rdrict, n <br /> City Lot Sae PM <br /> Job Address 416 Jc 55�U A�� i <br /> i Ums hone <br /> ..��nA. .T1 A py(� [�intC��' _ Address <br /> Owners Name =- - _ _ I <br /> ' icense No. Phone <br /> ~ Address pE$TRUCTION ❑ <br /> Contractor (✓ <br /> NEYV WELL_ ,.� WEL SYSTEM <br /> REPAIR ❑ OTHER 6 <br /> TYPE OFA/PUf"fP' -- SYSTEM REPAIR ❑ - <br /> PUMP INSTALLATION ❑ LINES pl SAL FLD. PROP. LINE <br /> SEWER —� <br /> _- <br /> DISTANCE TO NEAREST; SEPTIC TANK AGRICULTURE WELL OVER WELL PITS/SUMPS. <br /> FOUNDATION �r `- <br /> . - TYPE OF WELL PROBLEM AREA CONSTRUCTION SP IFICATIONS Dia.of Well Casing _ <br /> INTENDED USE pia•of Well Excavadfun—�—,/n•L-D— t-^ <br /> I ❑Industrial� G Open Bottom X Manteca • 1 SpecfFtcaaons _ <br /> ❑ Tracy Type of Casing_. of Grout <br /> ❑ Domestic/Private X Gravel Pack Depth of Grout Seal Type O <br /> I ❑ Other ❑ paha ' <br /> El Public Surface Seal Installed by <br /> Irrigation, �pPro%. Depth ❑ Eastern State Work Done <br /> Type of Pump r H.P. _ <br /> r Repair Work Done ❑ r $eating Materiel(top 50') <br /> Welt Destruction ❑ Well Diameter - <br /> Depth Filbr Material i8alow fi0'1 rmihed%Public sewer is <br /> i available within 200 feet.? (� <br /> TYPE OF SEPTIC WORK: NEW INSr RELATION ❑ REPAIR/ADDITION ❑ DESTf1UCTION ❑ INo septic system pa <br /> F Installation will serve: Residence <br /> _L Commercial_ Other C1 <br /> I Number d Irving units: Number of bedroomsWBier table depth <br /> Character of soil to a depth of 3 feet: CapacityNo. Compartments ` <br /> ❑ Type/Mfg / — V <br /> SEPTIC TANK � Method of Disposal (D <br /> 1 PKG.TREATMENT PLT.❑ Foundation Property Line <br /> 1 Distance to nearest: Well <br /> _ Total length/size <br /> l LEACHING LINE O No.8 Len4th ar lines — Foundation Property Line <br /> FILTER BED ❑ D-Istance to neared: We" <br /> ( I Size Number <br /> SEEPAGE PITS ❑ Depth - Property Line <br /> Foundation— .'. <br /> ' SUMPS " ❑ Distelce to nearest! We11 - <br /> DISPOSAL PONDS ❑ <br /> l hereby certify that I have prepared Chia application and fiat the work vnll bo done in accordance whh San Joaquin county ordinances,state Wws,and <br /> shall nor <br /> I rules and regulations of the San Joaquin local Health Didricl. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in �of California."CwtractWhich hiring or ub-com OrCtiinglsignature <br /> employ all person in such manner as to become subject to workrnan a corn mma is issued,I she%employ persons subiect to workman's cornparna- <br /> certiFres the following:-I certify that in the pertommnce of the work for which this pemrh <br /> t tion laws of Califomia:' <br /> io . Compo w on averse side. <br /> The appli n d call for all mqui inspect Date: u- <br /> F Tide: <br /> Signed <br /> I R DEPARTMENT US ONLY / <br /> Lr 'yJ �O Dais Area ` �— <br /> //�'�!/O?Lf a/ <br /> Appilcation Accepted by .rE :f - pate <br /> Ph or Grout Impaction by <br /> Date Final Inspection by <br /> Additional Commerna: O Lodi 389-3621 ❑ Manteca 873-7104 ❑Tracy 83rre385 <br /> ❑ Stk 4666MI Ave.,P.O. Box 2008. Stk.,CA 85[01 <br /> Applicant- Return dl Copus to: Environmental Health Permit/$ervxxss 1801 E. Hezahon <br /> ^' RECER/ED BY DATE PERMIYNO. <br /> _ FEE AMOUNT REMITTED . CASH ��� <br /> i' INFO AMOUNT DUE... _ Oy <br /> Ell 1124 taEv.1/a W <br /> EH 1420 - ��' <br />