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r <br /> r <br /> APPLICATION FOR PERMIT <br /> ` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> 'Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) I <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or kwan the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1882 for Well/pump and the Rubs and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address <br /> G'Io �a C�,N�/hc.,l�' Lot sire .� PM <br /> Owner's Name r=� Addrew 0 <br /> Contractor's Name <br /> �(�/^/fj2 License No. ptx" <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C; <br /> PUM'INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> .._ C <br /> FOUNDATION _AGRICULTURE WELL OTHER WELL__._-- PITS/SUMPS — QG� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dle WeA Casing <br /> Industrial ❑ Open Bottom U Manteca 0'�.of NMI Excavation <br /> ❑ Domestic/Private ❑ Gravel Pack T3 Tracy Typo of rN ry Sy"ofat u <br /> ❑ Other Depth of Grout Seal <br /> C Public Typo of Grout <br /> C Delta <br /> C S <br /> Irrigation --Approx. Depth ❑ Eastem urfsa SNI Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done a <br /> Well Destruction ❑ Well Diameter S4el tg Material(top 60') <br /> Depth Filler Material(Beiow 60') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION❑ DESTRUCTION ❑ (No septic system Permitted it F'bale sewer is <br /> eva9able within 200 feet.) <br /> Installation will prve: Residence— Comrrwrcial_ Other /A CC N't t4,/ <br /> 1. <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: ��,��' Gam' / ��/! !� Witter table depth <br /> Capacity_— No. ComW►tl,W is <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT.C Property lirN <br /> Distance to nNrpt: Well _ Foundation <br /> LEACHING LINE ❑ No. 8 Length of lines <br /> Total Wtgthlsi>" <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> G Depth Sin Number <br /> SPITS Foundaton Property Line <br /> SUUMPSMPS ❑ Distance to dearest: Wall <br /> DISPOSAL PONDS ❑ <br /> I herby otrt)fy that I have prepared this application and that the work M work will be doaccordance with San Joaquin county ordinances,ante Ia1lvs,and <br /> Nip and regulations of the San Joaquin Local Heath+District. 1 that in the peAormanca o1 the work for which this permit Is fpued,I shah not <br /> Home owner or licensed agent's signature certiflet the following:" tsntMy <br /> Home Ky person In each rsnrwr N to bacons eub)ect to workman's compensation laws of CNMornla."Contractors hirMp o sub-contacting signature <br /> certMlaa fM fo/owing:"1 certify that M the performance of the work for which this permit M issued.I shell employ persons subisct to workman's compensa <br /> tion Wlrs of California." � �'�8 - <br /> Title: <br /> must call for an . Complete drawing on reveres side. —!�The , r ` � Date: > <br /> sivr»d <br /> FOR DEPARTMENT ISE ONLY M L-1 O V Area Q/ <br /> Dan <br /> 5S L <br /> Pit or °"ELi��Y L E^ rN _� 2 Final 1 by <br /> pate ; <br /> Pit o Grout 1 by oar ,y <br /> Additional Comments: <br /> ❑ SdStk c �,�1 C385 <br /> Lodi 33821 ❑ Manteca 823.7104 ❑Tracy 8354386 <br /> 0 t-Return all copies <br /> Em*onrtsrttal llemtth Pe mIt/Servkw 1001 E. Haze ton Ave.. P.O. Box 2008, Stk.,CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED �/1SN RECEIVED BY DATE PERMIT NO. <br /> . EN 1}M INV w/tT <br /> EM 147a <br />