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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E { <br /> 1601 E. HAZEL T ON•AVE.,.14 STOCKTON, CA <br /> Telephone (209).466-6781 <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED { <br /> ti �� {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 H compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/.pump and the Ryles and Regulations of the San Joaquin <br /> • <br /> Local-Health District. �y ,w. <br /> , L <br /> 347/4 4ob Address � <br /> City 'Lot Size <br /> Owner's Name <br /> JII] Address �ni <br /> _ :o Phone -46?T� <br /> Contractor 54/7- µ w" <br /> TiYPE OF WELL/PUMP; License No. Phone <br /> NEW WELL ❑ WELL REPLACEMENT ❑ ..G DESTRUCTIO <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ � r ' / J <br /> DISTANCE TO NEAREST: SEPTIC TANK ..OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. . PROP. LINE <br /> FOUNDATION `AGRICULTURE WELL <br /> I� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPOCiFI ATHER TiONS PITS/SUMPS <br /> ❑:Industrial <br /> 11 Open Bottom ❑ MantecaD,a �1 <br /> O!Domestic/Private ID Gravel ❑ Tracy Type of Casing <br /> el Pack . of Well Excavation Dia. of Weil Casing F` <br /> Ei Public ❑ Other ❑ Delta.- Specifications <br /> Depth of Grout Seal Type of Grout <br /> O'irrigation —Approx. Depth ❑ Eastern <br /> Repair Work Done ❑ Type of Pump H P Surface Seal Installed by <br /> Weil Destruction !/. State Wor Done t +9 <br /> II Weil Diameter) Sealing Material (top 50')... h�T-t) <br /> I Depth Filler Material (Below 50') �Y / <br /> E OF SEPTIC WORK: NEW INSTALLATION ❑ REPAI% R/ADDITION ❑ DESTRUCTION LJ (No septic system permitted if public sewer is <br /> lr available within 200 feet.) <br /> �stallation w e: Residence, Commercial_ Other <br /> Number of living units: '"Number of bedrooms <br /> Character of soil to a depth of 3 fee , f <br /> SEPTIC TANK ' Water table depth <br /> ❑ Type/Mfg `" ' Capacit <br /> PKG. TREATMENT PLT. ❑ ' ' y No. Compartments ' <br /> Method of Disposal <br /> i Distance to nearest: Well" ation <br /> i Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED To th/size <br /> ❑ Distance to nearest: Well Foundation Prope e <br /> SEEPAGE PITS ❑ Depth Size <br /> SUMPSNumber <br /> ❑ Distance to nearest: WellFoundation <br /> DISPOSAL PONDS ❑ Property Line <br /> 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 /> emploHome 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 /> y 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: certify that in the performance of the work for which this permit is issued, I shall em la <br /> tion1laws of California." p p y persons subject to workman's Compenure <br /> "q ; <br /> The applicant1111,111 all for all requirein ions. Complete drawing on reverse side. <br /> 5igrid <br /> Title:_. ce Date: 3/ <br /> I FOR DEP RTMENT USE ONLY " f <br /> I <br /> Application Accepted by �y 3 I <br /> I Date H Area <br /> Pit or Grout Inspection by Date ) <br /> Final Inspection by Date CJ <br /> Additional Comments: I, 61 <br /> ❑ S;k 466-6781 ❑ Lodi 369-3621,� 11 Manteca 823-7104 <br /> Applicant- Return all copies to: Environmental Health PeC1 Tracy 835 63g5 <br /> rmit/Services 1601 E. Hazelton Ave.,'P.O. Box 2009, Stk., CA 952018 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY "..DATE ' <br /> PERMIT`NO. <br /> 1114311- <br /> EH 14-24[REV.5/5 5} O.r j#-o <br /> EH 1426 J1/' r <br />