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ate.. <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6*"" . <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ` r (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 /> f Local Health District. <br /> '`Job Address 4 S.�a� •�--�-�A h e rte _ City Lot Size IZACer?,f PM <br /> Owner's Name 4 Address Phone <br /> Contractor .rtv 1v p Addressg400 Rl—00 y -,r a License No. 6C9-_Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> �+ % IN ALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAR ,d6`LP AN SEWER LINES DISPOSAL FLD. PROP. LINE <br /> k FOU TIO AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE LL PROBLEM AREA CONSTRUCTION SPECIFICL�WNS ' <br /> I <br /> F ❑ Industrial L1 Open ❑ Manteca Dia. of W ca Dia. of Well Casing <br /> ❑ Domestic/Private 11Grav ck El Tracy , T rngg yet+ Specifications <br /> i°l Public fl � C� ❑ Delta epth of Grout Seal Type of Grout <br /> t z <br /> F I I Irrigation _ ppro Depth I rn Surface Seal Installed by <br /> of Pu n H,P. State Work Done <br /> F—PEF <br /> truction ❑ We Diam r Sealing Mat i <br /> De h F low 50'1 — V1 <br /> SE I' K: N W INS "I PAIRlADDITION DESTRUCTION I l {Ne septic system permitted if public sewer is <br /> available within 200 feet.) <br /> t a� <br /> Installatiodige: Rest ence Commercial Other <br /> Number of living units: Nu of bedrooms b <br /> i Character of soil to a depth f 3 fe t: Water table'depth <br /> F EPTIC TANK ❑ ype/ o Capacity No. Compartments _ <br /> KG. TREATMENT PLT. 0 a Method of Disposal <br /> istance to nearest: Well oundation Property Line <br /> �r <br /> EACHING LINE ❑ I lo. & Length of lines t Total length/size.' <br /> ILTER BED ❑ I listance to nearest: Well Fo a ion Property Line <br /> L <br /> Lhb <br /> E PITS i I apth Size V',r Number J <br /> I. f/7 istance to nearest: Well� Foundation z Property Line <br /> I AL PONDS ❑ <br /> certify that I have pre ared this application and that the work will be done in acco\e ,,h Joaquin county ordinances, state laws, and <br /> r d regulations of the Sa Joaquin Local Health District. <br /> wns or llii'e a signature certifies the following: "I certify that in the perfoork for which this permit is issued, I shall not <br /> by person in such manner as to become subject to workman's compensation laws ntractor's hiring or sub-contracting signature <br /> certifies the following: "i certify that in the performance of the work for whichthis permit is iploy persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must II for all required inspections—Complete drawing on reverse side. <br /> Signed X Title: Date: q <br /> OR DEP RTMENT USE ONLY <br /> r Application Accepted by DateArea <br /> Pit or Grout Inspection by Date Final Inspection by Date,f�4 <br /> Additional Comments: . <br /> ❑ Stk 466-6781 ❑ 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 /> INFO AMOUNT DUE AMOUNT REMITTED CK ECEIVED BY DATE PERMIT NO. <br /> ♦.EH 13-24 tREV,1i851 t <br /> E41 14.26 <br />