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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E)HAZEL T ON AVE., STOCKTON, CA <br /> . . Telephone (209) 466-6781 ` <br /> PERMIT EXPIRES i 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 San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and-the Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> ,�.3 I.,,tl,_�w�4-c�%�.c.-T-'�-✓E 4 -�--�J,,J .,.Zr�_ �[`7 --t p <br /> Job Address -o ISS sr S'Q f ,f SSG` ! L WfK Lj City "'}Lot Size PM <br /> Owner's Name 6 o r L1.f <br /> Address T:isffi----'- -- -- <br /> ContractorJl�b`' rllcr'-r) "000 +&ddress 30 J• F- Sy -S <br /> NLicense . 2i L�Phone `fes t 3�I <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION, <br /> ~; El REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK �, SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL b OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well EZeavdltion Dia. of Well Casing* <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing' Specifications <br /> ❑ Public El Other ❑ Delta Depth of Grout Sea Type of Grout 1 <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Agrfece.SeaI-Insta Ied_by . _ (" <br /> Repair Work Done ❑_ Type of Pump <br /> H.P. State ork Done`1,` p1-1N— k<•tom <br /> Well Destruction ❑ Well Diameter 5eafngMate ial flop 50'I <br /> Depth Filler Material (Below W544` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRU TION ❑ (No septic system permitted if public sewer is F <br /> 3 available within 200 feet.! <br /> Installation will serve: Residencen�_ Clmmercial Other . <br /> Number of living units_ Number of bedrooms . <br /> Character o i to a depth of 3 feet: Water table depth <br /> SEPT ANK ❑ Type/Mfg Capacity No. Compartments <br /> G. TREATMENT PLT. ❑ , Method of Disposal I <br /> Distance to nearest: Well Foundation _ Property Line <br /> LEACHING LINE ❑ No. &_Length•of linesAl T tal length/size "� C <br /> FILTER BED Distance to nearest: Well Foundation Property Line Yf <br /> SEEPAGE PITS ❑�D�epth-----� Size - A1--t Number <br /> SUMPS �❑ Distance to nearest Well Foundation w Property Line <br /> LYONf <br /> DISPOSA DS ❑ P i <br /> I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with-Soh Joaquin county ordinances, state'laws; ar__,_ ` <br /> rules and regulations of the San Joaquin Local Healthollowi <br /> District. 1 � <br /> Home owner or licensed agent's signature certifies the fng:"I°certify that in the=performance of the work for which this permit is issued,'I shall roti( <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signatur <br /> certifieM — Date <br /> :"I cert that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compenur� <br /> tion laia." <br /> The apsr,call for I required inspections. Complete drawing on reverse side. t <br /> SignedCao - Title: NE�-r� Date: � 7-1 5 <br /> FOR DEPARTMENT USE ONLY <br /> Applicad by Date - Area <br /> Pit or Gion b _ Date ina Inspec-on by Date <br /> Additional Comments: o� e <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835- <br /> R <br /> Applicant-'Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE z i <br /> INFO AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMIT"NO, <br /> + EH 13-24IREV. /1351 1 , K <br /> EH(426 ] <br /> I <br />