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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 'I'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. <br /> Job AddressC/� 2_0-0-C e447City Lot Size PM <br /> t p <br /> Owner's Namel!l�Z -d l'v Address `s `! e%rQRlr/6� Phone <br /> Contractor S.10L �X Address my S�"s�m'" '"Clcense No.30 5-7-21 Phone <br /> TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION FD SYSTEM REPAY('❑ THER ❑ ¢ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> j FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications) i <br /> f'1 Public i1 Other ❑ Delta Depth of Grout Seai Type of Grout <br /> 1 <br /> 1 I Irrigation Approx. Depth I I Eastern Surface Saal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction 11 Well Diameter Sealing Material Itop 50'1 <br /> 6 Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION (:1 REPAIR/ADDITION I�DESTRUCTION I 1 INo septic system permitted it public sewer is <br /> available within 200 feet.) l i <br /> Installation will serve: Resi encs Commercial Other <br /> t <br /> Number of living units: Number <br /> �of��bedrooms f <br /> Character of soil to a depth of 3 feet: CAR, LO 1lon, Water table depth <br /> SEPTIC TANK [st TypelMfg ��lti1.� `a' Capacity ltd�� No. Compartments — <br /> PKG'. TREATMENT PLT. ❑ ` Method of Disposal l <br /> s Distance to nearest: Well Foundation f Property Line /00 1 l <br /> I <br /> LEACHING LINE LY No. & Length of lines � t0 f Total length/size f l <br /> i <br /> FILTER BED ❑ Distance to nearest: Well 00 Foundation Property Line J0 f <br /> f � <br /> SEEPAGE PITS l4--Depth ?-5'! Size -36 r� Number -.2,_ �? <br /> SUMPS 0 Distance to nearest: Well .2-0 1 OFoundation ��r Property Line'S�d <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that-the work will be done in accordance with San_Joa'qu`in county ordinance's, state laws, and <br /> rules and regulations of the San Joaquin Local Health Dristrict. _, ' ..... - Cr <br /> Home owner or licensed agent's signature-cert)ff ies,the following: "I-(Icertify 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 6ecorfteu'b1e'cfTo w`orkah'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,l shall employ persons subject to workman's compensa- <br /> tion�laws of California." <br /> Thelapplicant must call for thspections. Complete-Urawing on ra`Q­0�se side. r ' <br /> �l rl <br /> Signed X� r #a, i Title: Date <br /> y ,vk�i <br /> FQRi DEPARTMENT USE-ONLY' <br /> Application Accepted t - Date l-2—O � Area l <br /> �r Grout Inspection by �F ate Final Inspection b T 4y//T2sf.� }} ate <br /> Additional Comments: c i <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 ❑ Tracy 835-6385 I <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> -- I <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> ov <br /> +.Hi13-21(REY.rinS) ��'05 ' /J<40 1/ 14; <br /> EH 11-26 /,3 Y-iJ /f <br />