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APPLICATION FOR PERMIT �4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �1L1 <br /> 1601 E. HAZELTON ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �, E98g <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 describe cl larsEA <br /> �a�plib0lion <br /> this <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 e San Joaquin <br /> `Local Health District.. p�, <br /> Job Address (��7Z YV�ZIER 10-d illw City. Lot Size PM <br /> Owner's Name Address �� Phone <br /> Contractor t Address 4=RLR4 Wicense No, Phone <br /> :TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION )Vrjff�A ,0 SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ,SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 11 Public f 1 Other F1 Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation --.Approx. Depth i I Eastern Surface Seal Installed by _ <br /> 'Repair Work Done ❑ Type of Pump H.P. State Work Done 77A <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') > )) /�—� &11 f <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> " t available within 201 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units:7z Number of bedrooms I w <br /> Character of soil to a depth of 3 feet: ; ; Water table depth <br /> SEPTIC TANK ❑ Type/Mfga — Capacity f r No. Compartments <br /> PKG. TREATMENT PLT. 171i ` W <br /> !i. Method of Disposal <br /> Distance to nearest:- W611 FoundationProperty Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size{ <br /> FILTER BED ❑ Distance to nearest: "' Well Foundation 'Property Line U ` <br /> x `a <br /> i SEEPAGE PITS l I DepthSize Number <br /> r � <br /> SUMPS ❑ Distance to nearest: Well foundation Property Line <br /> DISPOSAL PONDS Cl <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. r <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." - ` <br /> The applicant equir Complete drawing on 3p^so side. <br /> Signed X �,� it[e: <br /> � Date: <br /> is <br /> FOR QEPA MENT USE ONLY12 a �AA <br /> i Application Accepted by y Date / Area V <br /> . I <br /> Pit or Grout Inspection by Date Final Inspection by zf Yjd'�Yl Date d <br /> Additional Comments: <br /> ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 - ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20D9, Stk., CA 95201 <br /> CK <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> a EH.13-24IREV.I/A5) 1 EH, 4-28 , 11 <br />