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o APPLICATION FOR PERMIT <br /> N JOAQUIN LOCAL HEALTH DISTRICT <br /> q�`J 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 G <br /> t� vv: :. <br /> - � PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDL�� <br /> N <br /> (Complete in Triplicate) <br /> AppFtation is Neieby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein �'p7�F1ir{ lication is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the RulessNg� tiQpt•}�`e�San Joaquin <br /> Local Health District. �j <br /> Job Address cit /YD/t77y 1 F/471u i/L _– I City/ ,1W7L-" ___ Lot Size PM <br /> Owner's NameA,3V/gL V/ <br /> DADS �iA r% Address / , Phonr <br /> / doe/ <br /> Contractor V Address/l'XZ 49'�Z6 ��9r►�; License No._Z1Z8&3V Phont "7% <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT E7 DESTRUCTION ❑ 3 c <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 114, <br /> DISTANCE TO NEAREST: SEPTIC TANK NA SEWER LINES AtV' t DISPOSAL FLD. PROP. LINE^'L-sr <br /> FOUNDATION /'d/4 AGRICULTURE WELL ?_ THEIR WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ARE,Q CONSTRUCTION SPECIFICATIONS ♦/ <br /> ❑ Industrial i❑ Open Bottom AManteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing PVC, —C/[] Specifications <br /> Int,-Rmrbtie�mpl,�}Rywy F110ther C1 Delta Depth of Grout Seal 10 Type of Grout CA!r*"%I=- <br /> r <br /> I 1 Irrigation Approx. Depth I I Eastern Surface Seal Installed by�leiswYti <br /> Repair Work Done ❑ ,.Type,of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material (top 50') <br /> P Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I E DESTRUCTION i I (No septic system permitted it public sewer is <br /> available within 200 fedt._) <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 t <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ (L Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines ` Total length/size ] <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line t <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS 0 Distance to nearest: Well Foundation 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 <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."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." CSAR JpAjM LOCAL HEALTH DISTRICT <br /> The applicant must call for all required inspections. Complete drawing on reverse side. ENVIRONMENTAL HEALk14 DIVISION <br /> Si ned X Title: r 7` SPEC! : 71 W A-P <br /> M <br /> '� t71+�rS S4t1/�1ss FOR DEPARTMENT US`NLY <br /> plica A p f f i LL Date Area <br /> Pit or rout Inspection, y Date o2r Final Inspection by ,w Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369.3621 0 Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> IFEE AMOUNT DUE AMOUNT REMITTEDCr-"3RECEIVED BY DATE PERMIT'NO. <br /> +• <br /> EK <br /> (REV. i 8 51 <br /> 11-28 1 <br />