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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 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 Or ina 61Va:549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> f Local Health District. <br /> J b ddress Y / �' •of Size PM <br /> GOwner's !Name � � �- ds :5.-3-30-S- Phone <br /> Contractor L ��� °��-�— Address 6 QLicense No. -30P .Phone �� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El— DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTENI.REPAIR F�"-• 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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS I <br /> D Industrial ❑ Open Bottom ❑ Manteca t Dia. of Well'Excavation 1 Dia. of Well Casing _�``► <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy t Type of,Casing_Y I Specifications <br /> i D Public ❑ Other ❑ Delta Depth bf"Grout Seale Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by ' f <br /> Repair Work Done Q Type of Pump H.P. 6 State Work Done t <br /> k Well Destruction 4❑ Well Diameter ` j Sealing Material (top 50') <br /> Depth `-' Filler Material {Below 50_1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION ❑ DESTRUCTION o septic system permitted if public sewer is <br /> ,i available within 200 feet.) . <br /> Installation will serve: Residence f A- L--Crommercial_ 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 EJType/Mfg Capacity�._0 No. Compartments ` <br /> PKG. TREATMENT-PLT-❑`;..._""`"" Method of Disposal ' <br /> Distance to ne t: Well # -Founda'on Property Line s <br /> ... _ <br /> II LEACHING LINE ❑ No'& Length cf lines Total length/sine.r <br /> c } V <br /> FILTER BED J�O Distanceso nearest: Well } Foundation""' Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> i SUMPS ❑ Distance to nearest: Well ( Foundation Property Line r <br /> 1 <br /> DISPOSAL PONDS ❑ ! <br /> I I hereby certify that-F 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 JoaquraLocal Health District. (J f tr7i f t s <br /> He 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`he following:"I ce ify that in th1perfance of the work for which this permit is issued, I shall employ persons subject to workman's compensa-tion laws o lifornia.'• p1< ffhe applicant all far all equir iCo tete r wing on veeSigne — Title: �/u�� R Date: r <br /> _. .a <br /> "FOR'DEPAI TIMEA'T USE ONLY <br /> —� --�� s . <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by 9 � r"dam Date <br /> Additional Comments: �� ��x� n <br /> D Stk 466-6781 ❑ Lodi 369- 1 ❑ Manteca 823-7104 ❑ Tr cy 835.6385 . : . .� <br /> Applicant'`Return all copies`to 'Environmental Health Pi&M !Services 1i�01�E.-.Hazelton Ave., P.O. Box 2009, Stk., GA 95201 <br /> Al <br /> FEE } L <br /> INFO AMOUNT DUE AMOUNT REMITTER RECEIVED BY DATE PERMIT NR`7 <br /> + EH13-24IREV.1/s57 $37 ���-Zf�S1p 3to <br /> EH 1426 <br />