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Stk 466-6781 0 Lodi 369-3621 <br /> <br />0 Manteca 823-7104 0 Tracy 835-6385 <br />Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave. . Box 2009, Stk., CA 952 <br />rot6q <br />APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />Application is heieby 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 />. Vs" Tr tal ga,levant CityTr Lot 5.c / 5-CI) Size 1' PM <br /> <br />Owner's Name ftrzo Platt (... 1-S. C--i) - Address Pe • 6uK --> 6 / I Phone (q/ 5)5P -AV1 <br />._T 32.41 F%--v -a.&vr..41:1 tzek Su.C4c:2- <br />Contractor tuimer et el0tabh6 title. Address 12-0,-- 61-.4:> (0,,'-e_14:-A. I. - 6:. 4 rika-License No C. (.; 0 27? 0 Phone teilb) 65 1.- it <br />TYPE OF WELL/PUMP: NEW WELL X.... WELL REPLACEMENT El DESTRUCTION D <br />PUMP INSTALLATION D SYSTEM REPAIR C7 OTHER CI <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 7.' 50 4*'. DISPOSAL FLD. PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (,At affached NV, 5) <br />i Industrial r] Open Bottom E Manteca Dia. of Well Excavation Dia. of Well Casing <br />1 1 Domestic/Private g'Gravel Pack X Tracy Type of Casing f V(-- Specifications <br />H Public X glikiedtall Of1 Ii Other f 1 Delta Depth of Grout Seal Type of Gput <br />1 I Irrigation "40' Approx. Depth I I Eastern Surface Seal Installed by I (PAU- e-7/1) laiati Pt- ahC-- - <br />Repair Work Done Ii Type of Pump H.P. State Work Done <br />Well Destruction 0 Well Diameter Sealing Material Itop 50') <br />Depth Filler Material (Below 501 <br />' OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I INo septic system permitted if public sewe <br />available within 200 feet.) <br />Installation will s• • Residence Commercial Other _ <br />Number of living units: umber of bedrooms <br />Character of soil to a depth of 3 feet: er table depth <br />SEPTIC TANK D Type/Mfg Capacity No. Compartments <br />PKG. TREATMENT PLT. 0 Method of Disposal <br />Distance to nearest: Well —.5 ation Property Line <br />LEACHING LINE 0 No. & Length of lines . . •th/size <br />FILTER BED 0 Distance t. • .. est: Well Foundation Pro.: me <br />SEEPAGE PITS Depth Size Number <br />SUMPS Li Distance to nearest: Well Foundation Property Line <br />i - ',SAL PONDS 1] <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 />rule's 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." <br />The applicant / m st call for all required inspections. Complete drawinR on ne_Lst side. --- 4 + feic42._ <br />4--- Signed <br />FOR DEPARTMENT USE ONLY <br />Application Accepted by AA-0"-e-A Date42'4/11L( Area t.o,e: <br />Pit or Grout Inspection by Date Final Inspection by 4--k:1-• <br />Additional Comments: <br />X Date. ki 1L.Ni( <br />Dat <br />+ EH 13-24 (AEV.I/ii i <br />EH 14-26 <br />FEE <br />INFO AMOUNT DUE AMOUNT REMITTED CK # <br />CASH RECEI\!ktr-B-_ -Y_ DATE - --PERMIT NO. <br />rz,