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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Teiephohe (209) 466-6781 <br /> i <br /> PERMIT EXPIRES 7 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 he "n d s <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules an , <br /> Local Health District. T application is <br /> l tions o h oaquin <br /> Job Address /'i'tt 5'.5-- 5o:' T:dcn scl, <br /> City : O Lot Size A0AC7'e-X <br /> PM <br /> Owner's Name 1*Ak7,11 y JZ g y <br /> dam.Address f+ so, s <br /> Phone <br /> Contractar ., O Address <br /> TYPE WELL/PUMP: License No.Yy�Phone <br /> NEW WELL ❑ WELL REPLACEMENT ❑ <br /> " PUMP INSTALLATION ❑ DESTRUCTION ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ OTHER [Ir � SEWER LINES �_,_� DISPOSAL FLD. <br /> FOUNDATION AGRICULTURE WELL PROP. LINE <br /> OTHER WELL PITS/SUMPS <br /> 1NENDED USE TYPE OF WELL PROBLEM AREA- CONSTRUCTION SPECIFICATIONS <br /> L1 Ind liestic/Private <br /> strial ❑ Open Bottom Manteca A <br /> ❑ Do ❑ ❑ T <br /> Gravel Pack Y Dia. of Well Excavation <br /> Tracy Dia. of Wel! Casing <br /> M Pubtic f_1 Other Type of Casing Specifications,' <br /> Fl Delta Depth of Grout Seal <br /> ., <br /> I 1 Irrigation -Approx. Depth I 1 Eastern Type of Grout <br /> Repair Work Dbne ^ ❑ 'Type of PumpSurface Seal Installed by <br /> H.P. _ <br /> Well Destructi6n. - ❑ Well Diameter State Work Done_ <br /> Sealing Material (top 50'} <br /> Depth Filler'Material f eelow 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1.1 DESTRUCTION ! J INo'septic system vailable within 2nD feet.] s permitted it public sewer i <br /> Installation will serve. Commer <br /> Residence cial Other <br /> a <br /> L- <br /> Number of living units: / Number of bedr8orns-� <br /> Character of soil to a depth of 3 feet: f <br /> SEPTIC TANKTypelMfg Capacity /;too Water table depth <br /> { <br /> PKG. TREATMENT PLT. ❑ No. Compari"ts-<Z V <br /> Distance to nearest; '' Method of Di <br /> spos�l ` <br /> t t Weil 10'f' i foundation 7D' ; <br /> ---.�_ Property.Line <br /> - LEACHING LINE ."- <br /> �T No. & Length of li '0 y <br /> FILTER BED13 Distance to nearest:.f Well Tota! length/size r <br /> Foundation Pr6perty Line <br /> i <br /> SEEPAGE PITS I I Depth <br /> Sire Number i <br /> SUMPS ❑ Distan4oa WellDISPOSAL P FoundationProperty Line! hereby certify that I have rep par and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San r h Dt�at t.tHorne owner or licensed agent's signe following: "I certify that in the performance of the worts 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,1 shall employ persons subject to workman's compensa- <br /> tion laws.of California-" I <br /> The applicant mucalf for all required inspections. Complete drawing on reverse side. <br /> Signed <br /> Title: ° <br /> Date: <br /> FOR EPART NT USE ONLY <br /> Application Accepted by <br /> Date `-� �? Area <br /> Pit or Grout Inspection by Date <br /> Final Inspection b - Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 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 <br /> ANFO AMOUNT 6qA AMOUNT REMITTED CK <br /> CASH .... t;�CEIVED BY <br /> DATE <br /> PERMIT NO, <br /> r.EH 13-24 tRkV.1/M 51 <br /> EN 14-26 <br />