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APPLICATION FOR PERMIT <br /> SAN JCAQUIN LO.^.AL HEALTH DISTRICT <br /> 1601 E HAZELTON AVE-, STOCKTON, CA � <br /> Telephone (209) 466-67P1 ,. <br /> 1 PERMIT EXPIRES i YEAR FROM DATE ISSUED ' <br /> (Complete to 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 ap4rrcation is F <br /> made in compliance with Son Joaquin County Ordinance Na So9 for sewage or No '862 for well;pump and the Rules and Regutattrons of the San Joaquin <br /> Local Heel'h District t - <br /> X i . / / I <br /> t Job Address � 5/Ea .�1/L W O d �l a City r ZV A ^ PM 1 i <br /> 4 Lot Size <br /> -ea F �r '',/ ��41 A an/ Phone <br /> Name /< �4 Address _ <br />�'s}. s� 1 > ` ` Contractor �7oC ;T iro <br /> /�N ddress.2/.A0 atAd0x: 8_R�_ )_iL^nse No.�,T74 9 6 Phone <br /> PE OF WEL./PUMP r NEW WELL ❑ WEL REP ENT Cl DESTRUCTION Q <br /> r LF PUMP INSTALLATION,'�� P ST TE EPPIR C3OTHER ❑ <br /> OIST&YCE TO NEAREST SEPTIC TANK I00 SEWER LINES DISPOSAL FLD PROP LINE <br />' 4_4 '� ; " FOUNDATION __ AGRICULTURE WELL OTHER WELL PITS/SUMPS if <br /> INTENDED USE _ } 4 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D Ind <br /> ustnal D Open Bottom ❑ Manteca Die of Welt Excays,on Die of Well Casing <br /> G Domestic/Private D Gravel Pack ❑Tracy Type of Casing Speelficarn.lts <br /> D Other Lr" Delta depth of Grout Seal _ Type of Grout_ <br /> D Irrigation �4pp ox De th ❑ Eeste rface Seat Installed b <br /> e 4 _ State Work Done <br /> Repair Work Dona 'l Type at Pum �l�P -- - y <br /> i <br /> We'1 Destruction ` !L Well Gramater _ Sealing M:,trial (top 50) <br /> - t <br /> Depth Filler Mateual{Below 501 3 <br /> 1rr TYPE OF SEPTIC W[%RK NEW INSTALLATION ❑ REoAIR/AODITI04 ❑ DESTRUCTIUi% 0 (No septic system pc mitred if public sayer is � z <br /> F ava,iable within 2Ci feet f <br /> Installation wil.serve Rescuer Comms tial T Ot`ar <br /> Number of Irving units Number of bedrooms <br /> Cha atter of soil to a depth of 3 feet __ Water table depth <br /> ' SEPTIC TANK ❑ Type,Mfg _ Capacny__ Nr Compartments <br /> r "Aeihod of 7i sal <br /> PKG Tk,.ATMENT PLT O �o � <br /> n Distance to nea est Well FOL-Idaiion— Property Line <br /> LEACHING LINE ❑ No & Length of lines Total length/size a <br /> FILTER BED ❑ Distance to ntsarest We 1 Foundation Property Line <br /> SEEPAGE PITS ❑ Depth ---Size Number <br /> SUMPS 0 Distance to nearest Well Foundation_ Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have preprred this application and that the work wilt be done in accordance with San Joaquin county ordinances state laws and <br /> ries and regula=+ons of the Son Joaquin Local Health District <br /> Home owner or licensed aFlnt s signature certifies the following I certify that in the performance of the work for which this permi,is issued, I shall rot <br /> employ any person,n suets manner as to become subiect to workman compensation lays of California Contractor's hiring orsub-contra-ling r,gnature <br /> E certrfres the following certify that in the performama of the work fol which this peimn is Issued 1 shall employ persons subject to workman s compensa <br /> tion laws of CeIr'omia <br /> s <br /> } The applicant must rali tqr all required inspections Complete drawirg on reverse aide 7 /7 <br /> Ti SignedL_r -- Dates 4S <br /> FOR DEPARTMENT USE ONLY <br /> s ^ <br /> Apphcs ion Accepted by _ Date Area s~ p�C <br /> z <br /> Prt or Grout Inspection by Da a Final Inspection by- Otte �r b <br /> Additional Comment - <br /> 1 ❑Stk 466-Ml G Lodi 369-3621 0 Manteca bi2:l 7104 D Tracy 835-6385 <br /> Applicant Return all copies to Environmenta'Health Perini /Services 1601 E Hazelton Ave P 0 Box 2409 Stk CA 95201 <br /> ' <br /> FEE AMOUN-DUL AMOI NT REMiTTEC CASH RECEIVED BY DATE PERMIT NO <br /> INFO <br /> I.). [REV 1/5�, <br /> EM 7426 <br /> l <br />