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APPLICATION.FOR PERMIT <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA { <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' <br /> (Complete in;Triplicate) Pr U 2-70 1Cf-7 <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 f the <br /> Local Health District: <br /> Job Address 01p� IS -'' i f�ls�/"�f cod City STOCK/—bo Lot Size - PM <br /> Owner's Name - Addresa`o&&o - S-'kq/ e<J� �� �� Phone <br /> i <br /> tlgr,'Ti�j p(,rm P P Zup� <br /> Contractor ,� Address License No.S3&0__&5 4 Phone ° <br /> TYPE OF WELL/PUMP: NEW WELt, WELL REPLACEMEN DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK I O r SEWER LINES _ DISPOSAL FLDAS' PROP. LINE <br /> FOUNDATION 0.,t_ AGRICULTURE WELL dZOJ[, OTHER WELL.A)QCT. PITS/SUMPS <br /> INTENDED.USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /� l <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of.Well Excavation Dia. of Well Casing CSl`r/ <br /> Domestic/Private Gravel Pack ❑ Tracy Type-of Casing Specifications 1, 1 <br /> ❑ Public 0 Other ❑ Delta Depth'of Grout Seal �� _ Type of Grout 7- ^ } <br /> Irrigation __ Approx.,Depth ❑ Eastern Surface Seal Installed by. { <br /> Repair Work Done ❑ Type of Pumpl __ H.P. - 4--5 Stpte W k Don <br /> Well Destruction ❑ Well Diameter .. ' Sealing Material (top 50'1 <br /> Depth �0 Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11REPAIR/ADDITION LJDESTRUCTION C] (No septic system permitted if public sewer is <br /> s available within 200 feet.) <br /> Installation will serve: Residence— .Commercial— Other f.R <br /> Number of living units-: Number of bedrooms [ <br /> Character of soil to a depth of)feet 4 Water table depth <br /> SEPTIC TANK ❑. Type/Mfg-0 Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Metho9.of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines y Total length/size i <br /> FILTER BED ❑ Distance to rnearest: Well Foundation . Property Line ) <br /> SEEPAGE PITS ❑ DepthSize `� <br /> ' Number <br /> SUMPS ❑ .Distance to.nearest: Well -FountlatioriProperty 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 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.=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 persons subject to workman's compensa- <br /> tion laws of California." I f <br /> The applicant call for all required inspe ti ns. Complete d ing on averse side. I <br /> Signed X Title: bate: <br /> FOR DEPARTM T USE ONLY <br /> Application Accepted by Date < P� rea ! <br /> p <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> A itional Comments: 0 rt1 i0A r <br /> ours o <br /> Stk 466-6781 ❑ Lodi 369-3621 0111 Manteca -7104 ❑ Tracy 8355-6385 0W(L/ A"-'C7 v(l-( <br /> A ;cant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> 4 <br /> FEE_ AMOUNT-DUE.-, —AMOUNT-REMITTED— —^-RECEIVED'BY­ --'DATE-- "_ --PERMiT'No. - T <br /> INFO <br /> + EM 4-24[REV.tix51 .,.t ,. .. -r_ - y: ,>. �i1/� <br /> EH 14-� �� �O VL41 t <br />