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4 �r� 1�r �SpP�.'f1G✓� <br /> APPLICATION FOR PERMIT , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT pND <br /> 1601 E. HAZELTON 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 S'dn 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. �o <br /> / fD �(f <br /> Job Address - f.2 Cit�y�d�n&21 `— Lot Siz MDQ' <br /> Owner's NameTZ— <br /> T., /s oa�L Phone V l <br /> Contractor's Name License No. 4 7 Phone o—3 3 <br /> _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L� <br /> Industrial 15 Open Bottom ❑ Manteca Dia. of Well Excavation - Dia. of Well Casing W <br /> ❑ omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> _ ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Dept Eastern urtace Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> L Well Destruction . ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted H public sewer rs 'a <br /> - available within 200 feet.) til <br /> 1. 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 <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <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 <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."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,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call r all required inspe ions. Complete drawing on/rJeverse si e. <br /> Signed X �r ✓� Title: e42=12t i:/ L Date: <br /> FOR DEPARTMENT USE ONLY Q- 74� <br /> " <br /> Application Accepted by ��'` Date a / Ara�a� _ <br /> _ Pit or Grout Inspection 6y Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 i 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6395 <br /> Applicant- Return all c pies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95101 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED BY DATE PERMIYNO. <br /> EH 1321(REV.10/931 <br /> s° 1-7 5'8' 1 1C'`1/ i <br /> EN 1425 <br />