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APPLICATION FOR PERMIT <br /> u <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES TYEAR 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 e <br /> Local Health District. <br /> Job Address Cityot Size PM <br /> Owner's Name °' �W Z 57-77 f! _Address ,Z/ 7- 10- s�C Phone 4V,6 07- <br /> � 7 <br /> Contractor � rSH vfF Address ##—f'*0rd:P)r License J5)t 3"Phone �p <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> ^� PUMP-INSTA•LLATIONs❑-- - - SYSTEM REPAIR ❑ -- — -OTHER ❑-- ^ - <br /> DISTANCE TO NEAREST: SEPTIC TANK =' - SEWER LINES ^ DISPOSAL FLD. PROP. LINE <br /> 7% FOUNDATION_- - " --� ..AGRICULTURE WELL OTHER WELL -- PITSLSUJ'MPS <br /> t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ^j <br /> * Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ rG el Pack -[-]--Tracy-- ­Type of-Casing - k - —Specifications , <br /> ("I Public ❑•Other ❑ Delta Depth of Grout Seal Type of Grout - <br /> i ti <br /> I Irrigation Approx. Depth I 1 Eastern Surface Seal Installed by - <br /> Repair Work Done L1 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 ~ — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system peffnitted'if public sewer is ; <br /> �� 'available within 200 feet.) <br /> Installation will serve: Residence A: Commercial—L Other tKeep` <br /> .:y <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:- el�Vv f Water table depth <br /> SEPTIC TANK ❑ Type/Mfg n� �` ' 6d4'YC Capacity f Zai No. Compartments T_ <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 4fo�_No. & Length of lines _ ' S Total length/size / p <br /> FILTER-BED ❑ Distance to nearest: Well s4'* Foundation IS- Property Line <br /> I <br /> SEEPAGE PITS Depth 2 S Size y Number <br /> SUMPS Ll 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 Di3trict. <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 /> employ <br /> hall not-employ any person in such manner as to become subject to workman's compensation laws of California.'-Gontractor=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 /> I The applicant must c r all required 'inspections. Complete drawing on reverse side. _ 7 <br /> Signed X Title: <br /> LCf�✓� Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area 5 <br /> Pit or Grout Inspection by Date _ Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 , ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> a,EH 13-241REV.r=A 51 Q• ,�. �.1 `�® bR�ol�lo �3/ 1 Li/q O O G <br /> EH 14-26 <br />