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' d r <br /> APPLICATION'_FOR PERMIT - ¢= <br />} SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> - Telephone (209).466-676i <br /> f PERMIT EXPIRES 1'YEAR FROM 'DATE ISSUED' <br /> {Complete in Triplicate} >~ v • s <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 Cdunty Ordinance No.5.49 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> f Local Health District. .�L�3,V4 4 - a.3F <br /> Job Address <br /> kt s tr ,s City" Lot Size �z`r Y•�- PM > <br /> Owner's Name /u.�„•Cr,,e. Address �-�.� �J -I ,,� � v <br /> Phone <br /> Contractor_ �� . �11 C�� 4 <br /> TYPE OF WELL/PUMP: se N01-A ce"Phone 2-1 ZS!-� <br /> NEW WELL ❑ . ELL RE LACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTAL ION ❑ '� '-��-- r �- j <br /> DISTANCE TO NEAREST: SEPTIC TAN S REPAIR-'I❑ � OTHER ❑ <br /> y ER L�LJRE <br /> DS �SPOL FLD. PROP. LINE <br /> FOUNDATION , AGL <br /> LWELL OTH WELL <br /> PITS/SUMPS <br /> INTENDED USE TYPE OF WEl l� R �L-Spp �rygT%GTIGNSPZWICATI,ON.S <br /> ❑ Industrial ❑ Open Bottom ❑ dA nteca _ �. of Well Excav`ion <br /> El Domestic/Private LDGravelof Casing Gravel Pack ❑ c a . Dia. of Well Casing <br /> ❑ Public y Specifications <br /> ❑ Other ? [ eIta Depth of Grout Sea! <br /> 12 Irrigation __Approx. Depth ❑pastern Type of Grout I <br /> _ Surface Seal Installed b <br /> y <br /> Repair Work Done El' Type of Pum --r ^ " ` - y' <br /> P H.P. State Work Done <br /> Wel! Destruction ❑ Well Diameter <br /> ( 9 Sealingalrial (top ) <br /> Filler <br /> Depth / M e a low 50 <br /> TYPE OF SEPTIC WORK: NEW INSTAL Lid,T!' REPAIR/ADDITION ❑ DESTRUCTION ❑ [No septic system permitted if public sewer i 1 <br /> Installation will serve: Residence (?c Other <br /> F available within 200 feet.) <br /> r amerce � <br /> Number of living units:-. Number of'bL rooms - <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Water table depth <br /> tt Type/Mfg Capacity - No. Compartments <br /> PKG. TREATMENT PLT, ❑ <br /> r Method of Disposal <br /> Distance ton t: W Foundation Property Line <br /> LEACHING4LINE No. & Lengtl if lines /� y a <br /> FILTER BED ❑ Distance to I Total length/size <br /> nearest: Well <br /> SW_ GE PITS Ll Depth f Size - <br /> f i / <br /> S_ MPS ❑ Distance to nea st: <br /> AL PONDS E2 ... Well <br /> tuber f <br /> Foundation PeropeLi <br /> .. n <br /> e <br /> ISPOS -- i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordina ces, state 1";, and + <br /> ' rules and regulations of the San Joaquin Local H h District. <br /> Home owner or licensed agent's signature certif' s t e following: "I certify that in the performance of the work for which this permit is issued, 1 S411 not <br /> employ any person in such manner as to becoI subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:"I cce that in the dorm a of the work for which this permit is issued, I shall employ <br /> tion laws of Califf p y persons subject to workman's compensa- <br /> tion <br /> applican st I o I quire i S. Complete drawing anverse side. <br /> Signe Title: Date.,,: � ""D <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by rl J �. <br /> Date tJ Area <br /> Pit or Grout inspectiontbyJ5 � � <br /> DoleU Q.-t 1;-C , <br /> —�. y ate l I <br /> Additional Comm <br /> ❑ Stk 466 F1 1:1 Lodi 369-3621 ` anteca�zaz. _823-7104 ❑ Tracy 835 6385 _ <br /> Applica Return all copies to: Envir ea t ermit Services 1601 E. aze on ve., P.O. Box 2009, Stk., CA 55201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED°BY DATE ` <br /> PER T"N0. - <br /> +EH 13-24 /g5) <br /> EH 1426 Oce . . )(I ., <br />