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1 <br /> y APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E_ HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED LL <br /> (Complete in Triplicate) 6llk,& iCO- -7� I <br /> Application reby 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. / i <br /> (� l j '/;x <br /> A- <br /> Job Address r'i/ O N a� � _ - City �_r� Lot Size �"PM <br /> Owner's Name L. Lov 9' Adress F I (I W Q N 10 rJ "" Phane"Z 7� 00F V 3 <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ 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 /> ❑ Public ❑ Other ❑ Deka Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ___Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done l <br /> Well Destruction ❑ "Well Diameter Sealing Material [top 501 <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ..REPAIR/ADDITION ❑ DESTRUCTION <br /> (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: - Water table depth <br /> SEPTIC TANK Type/Mfg l7C y° ) +=- Capacity0_v2 te. fIAL, No. Compartments " <br /> PKG. TREATMENT PLT. ► F Method of DisposalC)o 1 <br /> Distance to nearest: Well Foundation 4Property Line S-1 4 <br /> LEACHING LINE ❑ No. & Length of lines - Total <br /> llength/size j <br /> FILTER BED ❑ Distance to nearest: Well d Foundation _r Property Line ; <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation t 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 I <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."Contractors 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 require inspections. gomplete drawing an reverse side. i <br /> Signed �� Title: Dam <br /> FOR DEPARTMENT USE ONLY � <br /> 1 <br /> Application Accepted by 7 Date � Area <br /> Pit or Grout Inspection b Date Final Inspection b Date <br /> 1!-'�P _ _ _ /J 4 <br /> Additional Comments: l +t_ I N 1 6 C( C Skw G� t o =sil V - <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 JkManLteca -7104 ❑ Tracy 835-6385 1& <br /> Applicant- Return all copies to: Environmental eath Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH13-24(REV.10/83) .1 <br /> EH 14-26 F <br /> .J J <br />