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} 0$ 4 <br /> } APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEILTON AVE., STOCKTON, CA <br /> Telephone 12091 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. L <br /> aqq l -3[+I - 9-3 h(4(&U ' PM <br /> Jab Address ,7c7City S. Lot Size O <br /> Owner's Name "�', 1­,�.�Ake Z/ Address 117 D A kc4 Phone <br /> Contractor's Name e MGl du No. 1 -'1/ _ Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ y WELL REPLACEMENT ❑_, y DESTRUCTION ❑ <br /> T PiJMP INSTALLATION'❑Y � ,� SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC,TANk SEWER LINES_ � -DISPO.SAL'FLtV ": �� PROP:-LINE <br /> i\"; V,FOUNDATION AGRICULTURE-WELL OTHER WELL PITS/SUMPS <br /> 'INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ lndustriaL.. ❑ Open Bottom ❑ Manteca 1 Dia.-of'Well ExcavationDia. of Well Casing j <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy �� ' Type of Casing Specifications n <br /> ❑ Public ❑ Other - ❑ Delta E C Depth'of Grout Seal Type of Grout ' <br /> ❑ Irrigation, --2Approx. Depth ❑ Eastern Surface Seal-installed by <br /> Repair Work Dane ❑ Type of Pump 1 H.P. `Y State Work Done D} <br /> Well Destruction ❑ Well Diameter I Sealing Material (top 501 T `- <br /> i <br /> € ; Depth ;Filler Material (Below 501 ) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑- DESTRUCTION ❑ (No septic system permitted if public sewer isuJ i <br /> I { F available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Oth'ert pce o e—. , A eAC# 4 t m6er, el v 6 <br /> Number df'living units: Number of bedrooms k -� 0� La r % <br /> Character.-of soil to a depth of 3 feet: D r " `?" Water table depth �. <br /> SEPTIC TANK ❑ Type/Mfg r�,X1 ]"/ACapaciNo. Compartments <br /> 4 - <br /> PKGTREATMENT PLT. ❑ r Method of Disposals <br /> a ^� fsta cn a to neareest: `Well `Foundation�Q Property Line S' <br /> LEACHING LINE r No. & Length if-iines- "f r', Total lerlgtosize _ <br /> FILTER'BED ,❑ Distance to nearest: Well 7-dd Foundation 40 . 'Property Line 9- f <br /> SEEPAGE PITS l Depth Size____-,.r —7�� 1 tr Number <br /> SUMPS ❑ ` Distance to nearest:` �Welh Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,fstate 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 /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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." F <br /> The applicant must call for ail r uired ins ctions. Complete drawing on reverse sid <br /> 4 <br /> Signed X Title: Date: " <br /> } FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area o;Z r <br /> Pit or Grout Inspection by Date Final Inspection by DatdD 4 <br /> Additional Comm( <br /> Stk 466-6761 ❑ 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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> + EH 1324 CRfY.10183) <br /> EH 14.28 <br />