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r L APPLICATION FOR PERMIT <br /> �/✓[� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE' TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 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 cl_ L 64 Rd City Lot Size fO a.46"A­1 PM <br /> 1 CLow� <br /> Owner's Name Jlll� !-1'�Pm/ Address 1 Phone <br /> _ Eontractor-�:f:L:-E�-04 �-&p/g Address - License-No. Phone 7y <br /> TYPE OF WELL/PUMP: NEW WELL CGP- WELL.REPLACEMENT;'❑, DI=STRUCTION ❑ <br /> _. PUMP INSTALLATION kill- SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:_SEPTIC TANKSEWER 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 neopen Bottom ❑ Manteca pia. of 1Nell Excavation - Dia. of Well Casing n <br /> L,Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing` Specifications 1 <br /> M Public n Other 0 Delta Depth of Grout Seal d Type of Grout <br /> I I Irrigation JQ,Approx. Depth I ! Eastern Surface Seal Installed by i17h,Ued <br /> Repair Work Done ❑ Type of Pump .51-.1 is H.P. /'O State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 Q" <br /> Depth Filler Material (Below 50') <br /> CIS <br /> TYPE 0 EPTIC WORK, NEW INSTALLATION i l REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted i blic sewer is Q <br /> available within 200 f {� <br /> Installation will serve: esidence ____ Commercial— Other " <br /> r Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 fee . '' Water table depth t `] <br /> SEPTIC TANK ❑ Type/Mfg C ity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length nes Total length/size <br /> FILTER BED ❑ Distan o nearest: Well Foundation arty Line <br /> SEEPAGE PIT���Ll <br /> Depth Size _ Number <br /> SUMPS Distance to nearest: Well Foundation Property 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 y <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." <br /> The applicant must all for all���Complota drawing on reverse side. Cy <br /> Signed X Title: dCdrtl�CG.f Date: 51-13_�7 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date _- Area <br /> Pito Grout ns action b <br /> P Y Date " U f Final Inspection by Date <br /> Additional Comments: / <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 _ Cl Tracy 835-6385 - - -- <br /> Applicant - Return all.copies to: En,rironmentel Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE}NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY —T— DATETJyy Y PERMIT N0. <br /> +.EH14-24IREV.r/n51 \.(' //1� � /� '! <br /> EH 14-2f3 1 /lJ v�/ �— `/ /�r <br />