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APPLICATION FOR PERMIT <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 County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Jab Address �� /J ]�_ /�� �® City Lot Size r PM <br /> Owner's Name "�;/1rr.C�O/fe r�i-ECAC.Address Phone ` 4t*�3�` <br /> Contractor Address / X7..11. License No. Phone <br /> PE OF WELL/?UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION X <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLE6 AREA CONSTRUCTION SPECIFICATIONS �V <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private © Gravel Pack ❑ Tracy Type of Casing Specifications <br /> (`1 l <br /> Public (:1 Other fl Delta Depth of Grout Seal Type of Grout—__, r <br /> I I Irrigation --Approx. Depth f I Eastern Surface Seal Installed by <br /> Repair Work Done LJ Type of Pump H,P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') 1 <br /> Depth Filler Material (Below 50') ' 14 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence A!!!!0'Commercial— Other <br /> Number of living units: --./_ Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity ' No. Compartments N <br /> \ <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED I] Distance to nearest: Well Foundation Property Line v <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 fallowing:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant}mustccaa for <br /> all required in r <br /> ions. Complete drawing on reverse sid / /r� �y / �s <br /> Signed X_C.!� Title: _ �/Ua � G S �/✓O/r//�la W f.3 - �p <br /> - - bate: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byDateV Area <br /> Pit or Grout Inspection by o Date Final Inspection by Date t) <br /> 9 Additional Comments: i <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., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CKRECEIVED <br /> INFO �j{'� CASH BY DATE PERMIT'No. <br /> +.EH 13-21(REV.i/Ks) C.J - c} d � f'y'}�— <br /> EH 11-28 ✓J <br />