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APPLICATION FOR PERMIT <br /> I' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F ✓ 1601 E. HAZELTON AVE., STOCKTON, CA <br /> v lives.- 111 Telephone (209) 466-6781 <br /> f PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> '"` -1 iComplete in Triplicate) <br /> E C(�-qVL i�-c.r OSS-Cov-z <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 /> Local Health District. <br /> 16 <br /> Job Addres ! DRD City Lot Size <br /> pPM <br /> Owner's Name .1L1L�� � �/�'�J� Address 2#13F I2Gg f VO phone 36 <br /> Contractor NG Address DC EPOIi License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ ­WELCREPLACEMENT ❑' _ DESTRUCTION O <br /> PUMP INSTALLATION <br /> ;$� SYST REPAIR ~OTHER ❑ � <br /> DISTANCE TO NEAREST: SEPTIC TANK - � SEWER LINES , �,_. DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL A� OTHEft WELL . .e PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> k ❑ Domestic/Private ❑ Grave! Pack El Tracy Type of'Casing Specifications <br /> M Public ❑ Other k Cl Delta F DeptFi of Grout Seal Type of Grout <br /> 'bQ Irrigation _.Approxi Depth t I Eastern 'Surface Seal Installed by <br /> Repair Work Done A T ' <br /> ype of Pump — 1rZ H.P. State Work Done <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION l 1 DESTRUCTION.i I (No septic system permitted if public sewer is <br /> p available within 200 feet.I <br /> Installation will serve: Residence Commercial_ Other } <br /> D rv'.� <br /> Number of living units: Number of bedrooms t k� <br /> Character of soil to a depth of 3 feet:: Water table depth ` <br /> SEPTIC TANK ❑ Type/Mfg. Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 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 <br /> SEEPAGE PITS I I Depth Size Number <br /> r <br /> SUMPS Ll 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 taws 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." P. , <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: 9 7Date: <br /> S <br /> ,FOR DEPARTMENT USE ONLY <br /> Application Accepted by rJ r <br /> rea <br /> Pit or Grout inspection43 <br /> 1 <br /> Date A <br /> J Date7-22 <br /> Final Inspection by Date <br /> Additional Comments: # d <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 /> FEE AMOUNT DUE t AMOUNT REMITTED CK <br /> INFO i€ RECEIVED BY DATE PERMIT-NO. <br /> + EH 13-241REV.1/85) a } r'} l Cj,1 4�j1�(� 2(� <br /> EH 14-28 ! � � !/1 \. V I I"Cl5 • <br /> k <br />