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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZEL T ON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES TYEAR 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 FZSFS /=- X le -r e9,1- ,e/-2 City :57—& Lot Size PM <br />Owner's Name Address 1_...L <br />Phone <br />DUE <br />4 r�i�i*11G�C. <br />�t <br />Contractor/ <br />/x.m s Address ✓ 41Y2 G/>� r'a r� icense No. Phone ' <br />TYPE OF WELL/PUMP: <br />NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br />PUMP INSTALLATION 10 SYSTEM REPAIR ❑ OTHER ❑ <br />DISTANCE TO NEAREST; SEPTIC TANK SEWER L1NAn DISPOSAL FLD. PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS__ <br />INTENDED USE <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />❑ Industrial <br />❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br />( fJomestic/Private <br />❑ Gravel Pack ❑ Tracy Type of Casing____ i%, <br />,Specifications • <br />FI Public <br />❑ Other ❑ Delta Depth of Grout Seal TYP e of Grout ­ <br />I 1 Irrigation <br />_.-Approx. Depth I I Eastern Seal Installed by— <br />Repair Repair Work Done E] <br />Type of Pump,-V—A _ H. P. ��� State Work Done 6.}lt•€�,t,�71 <br />Well Destruction El <br />Well Diameter Sealing Material (top 50') TAW 3exA. "'f <br />Depth Filler Material iBelow 50'1 <br />TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION( I INo septic system permitted if public sewer is <br />available within 200 feet.) <br />Installation will serve: <br />Residence— Commercial_ Other _ <br />Number of living units: <br />Number of bedrooms <br />Character of soil to a depth of 3 feet: Water table depth <br />SEPTIC TANK <br />❑ Type/Mfg Capacity No. Compartments <br />PKG,_TREATMENT PLT, <br />❑ _ of Disposal <br />Distance to nearest: Well Foundation Property Line <br />LEACHING LINE <br />Cl No. & Length of lines _ Total length/size_ <br />FILTER BED <br />❑ Distance to nearett: Well Foundation Property Line <br />SEEPAGE PITS <br />I I Depth Y Size Number <br />SUMPS <br />Ll Distance to nearest: Well (Foundation Property Line <br />DISPOSAL PONDS <br />❑ i I <br />\3 <br />r rrercuy carr❑y that i have prepared tins application and that,tpe.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. <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 sub'iect 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 />• k <br />The applicant for II requiredd pections. Complete drawing onvr�e+y'�rsea. <br />-111-1Z Z- rJ <br />Signed )L<"�'/ �!`•�'���_` Titla: _ s" ! G� ��SJ�� -_ Date:t-.!p T <br />t <br />VF R,/DDEEPARTMENT USE ONLYApplication Accepted by -mit __ Date le <br />Pit or Grout Inspection by Date Final Inspection by , Date <br />Additional Comments: <br />U Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 635-6385 <br />Applicant - Return all copies to: Environmental Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br />EH 13-24 (REV. tin 5) <br />EH 14-26 <br />FEEAMOUNT <br />INFO <br />DUE <br />A NT Eh11TTED <br />CK It <br />CASH <br />RECEIVED BY <br />DATE <br />PERMIT NO. <br />V - f PLO <br />� <br />