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r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL—j ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I. (Complete in Triplicate) 1 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. Th;s application is ~ <br /> made in compliance with San Joaquin County Ordinance No.649 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 900 /lJ LDccfe,L ?11 City dOQ Lot Size PM s� <br /> f <br /> Owner's Name�c�� �IJS� Address 0 ( L.owC�CAC /� Phone <br /> Contractor's Name �� License No. Phone �� 1 <br /> TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT C DESTRUCTION ❑ <br /> PUMP INSTALLATION C SYSTEM REPAIR C OTHER C <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE {/ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <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 ❑ Gravef Pack ❑ Tracy Type of Casing Specifications } <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout— <br /> C Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done Q } <br /> Well Destruction ❑ Well Diameter Seating Material(top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION{Y REPAIRIADDITiON ❑' DESTRIJC}ION_ _U�loseptic_system-permitted if-public sewer is <br /> 1 <br /> ,Z-41 <br /> available within 200 feet.) d <br /> Installation will serve: Residence_ Commercial_ Other fJ9A Lea, <br /> Number of living units:A— Number of bed ms <br /> Character of soil to a depth of 3 feet: eA Water table depth i <br /> SEPTIC TANK C9--Type/Mfg Capacity No, Compartments 2— <br /> PKG. <br /> PKG. TREATMENT PLT.G1 { >~ Method of Disposal <br /> Distance to nearesr. Well r� Foundation Property Line <br /> LEACHING LINE A!-I' o. & Length of linesa- ��0 fC?�"hif. v Total length/size <br /> FILTER BED E Distance to nearest: wall .• ndation U r Property Liner <br /> 21 f <br /> SEEPAGE PITS [Sol Depth Number Z <br /> :r�-� � t . <br /> SUMPS ❑ Distance toTnearest: Well�s� Foundation .7 t Property Line 10 <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work w[ll"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,,]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:"4 certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workmen's compensa- <br /> tion laws of California." <br /> c j <br /> The applicant m 11 f all inspections. Complete drawing on reverse side. e <br /> Signed <br /> Tito: 00 A)X-& Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ���—� Area <br /> 02 z3– <br /> Pit or Grout Inspection by. Data Final Inspection by / Date�GLs2. <br /> Additional Comments: i 4,4' P l99D y <br /> C Stk 466-&781 ❑ Lodi 369-3521 ❑ Manteca 823-7104 ❑ Tracy 835-6386 <br /> Applicant- Return all copies to. Environmental Health Per_mit7Services.1601,E. Hazelton Ave., P.O. Box 2009, Stk., CA%M1FEE 'Y <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECOVED BY DATE PERMIT NO. <br /> Q <br /> .EH 1334 IREV.10/831145 <br /> G 19-5 <br /> EH 7428 <br />