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APPLICATION FOR PERMIT <br /> a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1641 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 is <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. .,1,,, ) <br /> Job Address N• Rgi. tCt4 S7~, City /,_/rgDCW .Lot Size �� PM <br /> Owner's Name/—.C>Ui-S Address Jr ZZ N. Phone K2£ "3:5Z V <br /> Contractor.Af&VZ/9NC-9 DRiN4AF- Address C,r' o �$ License No,iT®S3.Z Phone -3.Z 7 <br /> TYPE OF WELL/PUMP: NEW WELL / WELL REPLACEMENT ❑ IV DESTRUCTION ❑ <br /> PUMP INSTALLATION 4d' SYSTEM REPAIR ❑ OTHER ❑ <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 p, <br /> ❑ Industrial r ❑ Open Bottom ❑ Manteca Dia. of Well Excavation + �� Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of.Casing STS�'� Specifications <br /> IIP lic 171 Other TT ❑ DJta Depth of Grout Seal Type of Grout <br /> r <br /> 11' Irrigation- - �-3�n.!�'ApproK:�Depth astern.,..- - Surface Seal Installed-by-- - - -- `--- ------ <br /> Repair Work Done ❑ Type of Pum H.P, /J� State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth -j6��� Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'l REPAIR/ADDITION I I DESTRUCTION l 1 Wo septic system permitted if public sewer is <br /> w r available within.200 feet.) <br /> r <br /> Installation will serve: Residence= Commercial_ Other <br /> Number of living units: Number of bedrooms R <br /> Character of soil to a depth of 3 feet-4 Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity :.No. Compartments <br /> PKG. TREATMENT PLT. [I Method of Disposal <br /> "Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED' a ❑ Distance to nearest: Well Foundation Property Line , <br /> i <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS L71 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 District. <br /> r 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, I 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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> j, The applicant must call for all required inspections. Complete drawing onreverseside. <br /> Signed X 6 � Title: C3G+1r Date: ZZi��8�&� <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by W_� 9JN6,tf1 N1 Date "1` y� Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: r j <br /> F ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy- 835-6385 if <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> .f <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. <br /> r <br /> ♦.EH13-244REV.r n51 �Jr��, 35~s�� V� j fin+ <br /> EH 14-26 +/ <br />