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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> I Telephone (209) 466-6781 <br /> e <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:J,,7,7 2-1 ,E <br /> Job Address dorxq 6,9&j jZ"1_4;U 11114WILLCity S7c" A7Fan/ Lot Size 3AO Ar-RE PM <br /> I <br /> Owner's Name -C&AW7 l of,<41JIM,Autl♦Address ArWllf/D 6ZE4rn1 A/C Phone 2gly 4vocr`. O;9gr a <br /> i <br /> Contractor +-+�L/WPAtAAt rAddress <br /> I ZcY� Af..UT.S7 44Ar�License No. Phone <br /> TYPE OF WELL/PUMP: ' NEW WELL IH''• WELL REPLACEMENT 0 DESTRUCTION ❑ <br /> -4 !PUMP fNSTALLATION C7_ w SYSTEM REPAIR ❑ OTHER (Ir �., <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL'FLD•.'­ T PROP. LINE <br /> FOUNDATION' AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> " ❑industrial ❑ O an Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing (� <br /> ❑ Domestic/Private tH'Gravel Pack ❑Tracy Type of Casing Specifications t <br /> f'1 Public n Other n Delta Depth of Grout Seal ,3® l Type of Grout_.( C"t <br /> I I Irrigation "--Approx. Depth I ) Eastern Surface Seal Installed byif <br /> Repair Work Done ❑ Type of Pump I H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Stop 50'i <br /> l t <br /> " Depth t Filler Material (below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION i I'(No septic system permitted if public sewer is ,r <br /> ravailablb within 200 feet.) <br /> Installation will serve: Residence_ ICommercial_ Other <br /> Number of living units: Number lof bedrooms <br /> Character of soil to a depth of 3 feet: "( Water cable depth r <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal f <br /> t Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE• ❑ 'No. & Length of lines Total length/size <br /> FILTER BED ": ❑ Distance to nearest: Well Foundation Property Line. <br /> SEEPAGE PITS. I I Depth Size Number. <br /> SUMPS $ L1 Distance to nearest: Well Foundation C Property Line ' <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will lie done in-accordance with San Joaquin county ordinances,state laws,and <br /> rules and regulations of the,,San Joaquin Local Health District. <br /> 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 /> 1 r 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 parsons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant allj all re fired inspections. Complete drawing on reverse side. <br /> d i <br /> Signed X Za2 Title: Date: <br /> FOR DEPARTMENT USE ONLY �q <br /> Application Accepted b4by <br /> Date ---lS / Area Al ` r <br /> Pit r Gro t nspection Date L Final Inspection by Date <br /> Additional Comments:O Stk 466-6781 69-3621 0 Manteca 823-7404 racy 835-6385 - <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Slit., CA 95201 / <br /> t � <br /> • FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. j <br /> •� H13-24fHEV.I/Ass 3S. 00 �O.—�t� l <br /> 1H 14.29 W ;.as00 <br />