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APPLICATION FOR PERMIT 1 <br /> SAN JOAQUINLOCAL HEALTH DISTRICT <br /> f <br /> 1601 E. HAZEL, <br /> ON AVE., STOCKTON, CA <br /> Telepli�one (209) 466-6781 <br /> PERMIT EXPIRESd1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> • i <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 Address fo-lr a" -�� 1 /K City Lot Size PM <br /> Owner's Name � `�A— 5 wo� l Address !I Phone <br /> Contractor - 4' . Address License No. �9fl1i Phone ° <br /> TYPE OF WELL/PUMP: �.- ANEW WELLX WELL REPLACEMENT,O 'DESTRUCTION ❑ <br /> y PUMP INSTALLATION I SYSTEM REPAIR ❑ i OTHER ❑ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DIS L FLD. PROP. LINE i <br /> .s <br /> t FOUNDATION AGRICULTURE WELL '— O aRR WELL Z PITS/SUMPS L- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA <br /> LI CONSTRUCTION SPECIFICATIONS_ <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca E Dia. of Well Excavation Dia- of Well Casing <br /> Domestic/Private 'Gravel Pack ❑ Tracy !E Type of Casing_ � � f Specifications �, - <br /> I"1 Public Cl Other ❑ Delta Depth of Grout Seal ype of Grout _. <br /> I I Irrigation dZ'._Approx Depth I I Eastern Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well'Diameter Sealing`Material (top 501 ' <br /> Depth Filler Material (Below 501 ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIRlADDITIDN [ I DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> \� <br /> f available within 200 feet.) <br /> Installation will serve: .Residence Commercial_ Other <br /> r <br /> Number of living units: Number of bedrooms + <br /> r Character of soil to a depth of 3 feet! ! Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No.'Compartments <br /> t PKG. TREATMENT PLT. ❑ Method of Disposal <br /> ' r Distance to nearest: Well !' Foundation Property Line 1 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: ,s'WII Foundation Property Line <br /> SEEPAGE PITS I I Depth Size . Y t Number t <br /> SUMPS Ll Distance to nearest: Well foundation L Property Line <br /> DISPOSAL PONDS ❑ <br /> 4 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance V'-ith San Joaquin county ordinances, slatelaivs, and <br /> } rules and regulations of the San Joaquin Local Health DFstrict. II ° p <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance, <br /> f 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.laovs of.California.":Contractor's hiring or sub-contracting signature <br /> r certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject`[o workman's-compensa- <br /> tion laws of California." - <br /> L <br /> The applicant r req u"u ions. Complete drawit)g on,rever side. <br /> 5 <br /> t Signed XC sx 2�°s°a Title: �^ - Date: / <br /> EPARTMEIYT USE OT LY <br /> Application A opted by ti'Date ^2�'� L Area - <br /> Pit rout pection b Date Final Inspection by Date <br /> Additional Comments <br /> ❑ Stk A66-6781.— .•❑ Lod r_369 3621 - ❑-Ment ca -1123-7104-­­ ❑-Tracy -835-6385-- - -- <br /> Applicant- Return all copies to: Environmental Health Perm't/Se ices 1601 E,,Hazelton Ave.,=P.O. Box 2009,.Stk., CA 95201 <br /> �c�r '"J, -4i <br /> FEE MOUNT.OUE AMOUNT REMITTED �� CK RECEIVED BY DATE PERMIT*NO. f 1 <br /> CASH <br /> ..EH 13-24[REV7". <br /> -' _ J .. " [� ` ,� ��� . <br /> EH 14-26 t '� 4s 1� \ a-t: _l7 , <br /> _ + <br /> 01— I"� 1i� <br />