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APPLICATION FOR PERMIT <br /> l <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.�HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (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 Cou'ty Ordinance Na.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin I <br /> Local Health District. <br /> Job Address _a7too s< I�IG /f/, <br /> z;yla 4d e • City >a Lot Size_ :;�Z)aCOV 3 PM <br /> Owner's Name SrQ921 Qa01 ✓/9C • Address 154700 Phone <br /> ///.I <br /> /// ii '� 1 p <br /> Contractor (/.I O i .Address �1 D .S. L/�� D GT• License No, 99X46 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ Y OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSA&LD. PROP. LINE { <br /> FOUNDATION AGRICULTURE WELL OTWER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA--­CONSTRLJCTION SPECIFICATIONS r { <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> Ll Domestic/Private ❑ Gravel Pack ❑ Tracy t Type of Casing Specifications 4 <br /> FPublic ❑ Other Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation _AppFOX.dDepth I I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑may Type o Pump j- - H.P. State Work Done <br /> Well Destructio_n.,. O Well Diameter . Sealing Material (top 501 <br /> Depth Filler Material (Below 50 A <br /> TYPE OF SEPTIC.WORK: NEW INSTALLATION X REPAIR/ADDITION I I DESTRUCTION I } INo septic system permitted if public sewer is <br /> 4•• available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other sAe' <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: ?� Water table depth <br /> t � � z __ter _ 3 <br /> SEPTIC TANK 'Type/Mfg A� �G'apacrty t7 .=No.'•'Compartmenis <br /> .I <br /> PKG. TREATMENT PLT. ❑ Method of Dissposal':< e < <br /> tr r <br /> Distance to nearest: Well Foundation - �' Property Line /L 45F,•- `R= <br /> LEACHING LINE ❑ No.'&,Length of lines Total length/size14 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth •3 Size��XJ�Q _ Num 15 <br /> SUMPS Ll ,,,,.Distance to4nearest: �WeH //Q�� Foundation Jr6 ne 4d9r) <br /> DISPOSAL PONDS CK <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 permitis issued;I shall employ persons subject to workman's compensa- <br /> tion laws of California." r` " <br /> The applicant must call for all r quired inspections. Complete drawing on reverse side. / <br /> Signed X � __. Title: a 0 �I?C! 24 Date: 14 41-97 <br /> �,. FOR DEPARTMENT USE ONLY 1 2 <br /> Application Accepted by Date <br /> {o+.'��� y� Area 3 <br /> Pit or Grout Inspection b Date Final Inspection by �/ / Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.r CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMn'NO. <br /> INFO ASH <br /> r EH13-24(fl£V.1/e 5) <br /> EH a-29 - <br />