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r <br /> APPLICATION FOR PERMIT <br /> SAN JOAO.LIIN'(OCAL HEALTH DISTRICTf <br /> 1601 E. HAZELTON AVE., STOCKTON, CA �- <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED ` <br /> 4 (Complete in Triplicate) , �., - ,,.•�,r .. �.�, 4, r{ ';•, ., <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 Ryles and Regulations of the San Joaquin <br /> Local'Health District. <br /> Job Address <br /> c�a g� <br /> � • LotSiza PM <br /> Ci <br /> O Address r !-AQ�:[� - _ Phone <br /> y-a� �� <br /> Owner's NameA" <br /> y iLJ t n <br /> Contract f c Address !' �I License fVo. Z � Phone 6�� 10S <br /> i <br /> T OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ V. <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEARES TIC TANIZ SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUND A { AGRICULTURE WELL OTHER WELL F PITS/SUMPS �- <br /> INTENDED USE TYPE OF WELL PR AREA CONSTRUCTION SPECIFICATIONS t <br /> ❑ Industrial ❑ Oen bottom.. ❑ fiAanteca of WeIE'^Excavation ' Dia. of Well Casing <br /> El Domestic/Private 1-1Gravel Pack -E] Tracy Type of Specifications <br /> - ' <br /> ID Public L) Other �„��❑ Delta-'� '� Degth-of Grout Seal- ��'-°'--``� Type of Grout t <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by 1( <br /> Repair Work Done ❑ Type of Pump" H.P. ' State Work Done <br /> Well Destruction ❑ Well Diameter.A. Sealing Material rltop 501 <br /> Depth a ler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR DDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> c * <br /> available within 200 feet.) � <br /> Installation will serve: ResidenceCommercial_ rOther <br /> Number of living units: Number of edrooms C7` rr fjf <br /> Character of soil to a depth of 3 feet: 'l -P_ct Water table_depth 1 <br /> SEPTIC TANK ❑ T-- /Mfg Capacity N - No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal rr <br /> Distance to nearest: Well Foundation Property Line. r. <br /> LEACHIN ❑ No. & Length of lines Total length/sizes-- <br /> FILTER BED ❑ DistanceWell \� Foundation � Property Line <br /> • i � ` i <br /> SEEPAGE PITS © Deptht. Sizze. f. ftpPr <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> O a� <br /> DISPOSAL PONDS ❑ I <br /> hereby certify that I have prepared thisiapplication and that the 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. o <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for whichfthis permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of CalifoFnia." 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 applican ust call fo all r quired inspections. Complete drawing on reverse side. , <br /> Signed Y Title: V Date: <br /> ' _FDR DEP 1iTMENT USE ONLY <br /> Application Accepted by <br /> Date �e5 viz-- Area /.2— <br /> -Pit or Grout Inspection by Date Final Inspection by Date 30— <br /> C <br /> Additional Comments: -' <br /> ❑ Stk 4666781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 /> IFEE <br /> NFO AMOUNT DUE ;g� AMOUNT REMITTED CASH RECEIVED BY, DATE i PERM17'NO. <br /> + EH 13-241REV.1/855 <br /> EH 14-26 <br />