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} <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> ,ii PERMIT EXPIRES 1'YEAR FROM DATE ISSUED l <br /> (Complete in Triplicate) <br /> Application is heiehy 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 Address 2�,v� Q L f-\YV\"YY\A- -� City Trac Lot Size C Ph —_-.—- <br /> ryl; <br /> Owner's Name l5 Address r- Phone <br /> Contractor U�l k UT ji Ilk.LL— Address So License No.q D UA Phone 2S7A <br /> �...� TYPE OF..WELL/PUMP: NEW WELL ❑ "WELL REPLACE NT'❑.,# DESTRUCTION ❑ <br /> TPUMP INSTALLA ❑ SYSTE yEPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE q <br /> FOUNDATION ICULTUR ELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ARE CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial C] Open Bottom �C1 Manteca Dia. Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private -C Gravel Pack 0 Tracy Type <br /> ofr ig Specifications i <br /> Ll Public C7 Other { ❑'Dell ' yi Depth of Grout i Type of Grout- �'�N <br /> I I Irrigation .. Appr#x. Depth I I E term Surface.Seal;lnstalled _ <br /> Repair Work Done ❑' /Type of pump H.P. 1 - State Done j ( <br /> Well Destruction ,•E7,_;Well°Diameter Sealing Material (top 50'I I <br /> i Depth s >",Filler"Material Below 501 I s <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION _ STRUCTION I I INo septic system permitted iNpublic,sewer is <br /> available within 200 feet:) <br /> s <br /> Installation will serve Residence;commercial_ Other " <br /> Number of living units: Number of bedrooms 9`1 <br /> Character of soil to a depth of 3 feet: e-L Water table depth <br /> SEPTIC TANK ER =ype/Mfg t 'CapacityNo. Compartments <br /> f <br /> PKG. TREATMENT PLT. ❑ C p1-, € <br /> Ct` �� ��" Method of Disposal <br /> Distance to nearest: Well FoundationProperty Line <br /> LEACHING LINE L1YIVa. & L;ength of lines r �` �� ' } Total length/size <br /> FILTER BED s ❑ Distance to nearest: Well Foundation'r Property Line <br /> SEEPAGE PITS I I "Depth Size 1 Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I <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 taws, and <br /> rules and regulations of the San Joaquin Local Health District. y <br /> Home owner or licensed agent's signature certifies the following: ` <br /> g g g: "I certify that in the periormanca`of the,work for which this permit is issued, 1 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 /> ce ifies 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- I <br /> tiorf la Californi 1' r <br /> The applican m call f all quir ins ion om to drawing on verse"si e. <br /> Signe Title: �C — 1 Date: ` �� �� <br /> i <br /> CQEPARTME,NT USE ONLY <br /> Application Accepted y `4 a L Date — Area <br /> Pit or Grout Inspection, Date -IR Final Inspection by Date <br /> Additional Comments: 3 V <br /> ❑ Stk 466-6781 i❑ Lodi 369-3621 ❑ Manteca 104 t 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 /> i <br /> INFO ' x AMOUNT DUI:". AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. <br /> + EH 13-241REV.t/a51 <br /> EH 14-28 � � <br />