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Yom. r. APPLIC ION FOR PERMIT {" <br /> N JOAQUIN LOCAL 9E') LTT DISTRIL- <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 i <br /> made in compliance with San Joaquin County Ordinance No: 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> t, { <br /> Job Address !�"C. City ' M� Lot Size Ply <br /> Owner's Name t C 1 Y t�`5 "gddress J CJ r 2 t�T <br /> ��� 1 -r 5836 Phone 0 <br /> Y. �l�,,n <br /> ContractorA Addressti W q aN eE License No.c ;4 Jone 10004) <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK -&L= SEWER LINES _ >5_t DISPOSAL FLO.,.2 SZ PROP. LINE �S <br /> FOUNDATION �5 - AGRICULTURE WELL � OTHER WELL -^�Z�f 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 A <br /> 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing I/� t� <br /> ( Specifications ��► <br /> F1 Public F1 Other F1 Delta Depth of Grout Seal 1 Z'ZO Type of Grout r/ll ,t(W"V !fit <br /> 1 1 Irrigation —.Approx. Depth l 1 Eastern Surface Seal Installed by--C- k-MV' l <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> fa <br /> Depth Filler Material {Below 50') _ <br /> V YPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION l 1 DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) C <br /> , <br /> Installation will serve: Residence— Commercial— Other <br /> =� <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. p <br /> Method of'Disposa � <br /> Distance to nearest: Well Foundation Property Line, <br /> LEACHING LINE ❑ No. & Length of lines Total length4ize <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I 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 Di§trict. <br /> Home owner at licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 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." <br /> The applicant t all fo all re red inspections. Complete drawingon reverse <br /> Signed X <br /> Title: '� — Sid Date: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Date ! e <br /> Area a <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: e <br /> ❑ Stk 466-6781 0 Lodi 369-3621 C-1 Manteca 823-7104 El Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 200% Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO �} K RECEFVED 8Y DATE PERIAn,No. <br /> . 13-21(REV.rin5 r� �`-9r r� / e•' �� J <br /> EK f4-20 <br /> - Q �!- <br />