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' APPLICATION FOR PERMIT A�rA 3 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA - �. <br /> Telepho!)e (209) 466-6781" tit:tot:' <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APR <br /> (Complete ill Triplicate) ��1r{�RQ1�+ � <br /> f� q,� n+7 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work f/R0 Y EN r AAL H ! ° <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and�[Reegg�ulrfiN o'i 'Joa uin <br /> Local Health District.(�, q <br /> /!t�e7 21, t <br /> Job Address City "C7 +�-� - Lot Size PM <br /> 0 <br /> Owner's Name If!_A) Q lJ&S C-j MC <br /> ress � <br /> �y j Phone <br /> Contractor 'Ir Address4ELL�FIEP <br /> TYPE OF WELL/PUMP: NEW WELL ❑ CEMENT ❑ Dr STRUCTION ❑ <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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industria( _O. Onen Bottom -. Fl Manteca Dia of Well Excavation <br /> --Well - Dia. of Wel_,I�asing <br /> ❑ Domestic!Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> FI Public 1� Other ❑ Delta Depth of Grout Seal <br /> Type of Grout <br /> irl'Ir(igation __,Approx. De th I I�Eastern Surface Seal installed by, <br /> Repair Work Done L� Type of Pump H.P. Ca State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material itop 50') <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION f I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) 4 <br /> Installation will serve: Residence— Commercial— Other <br /> Numbpr of living units: Number of bedrooms , <br /> Character of soil to a depth of 3 feet: ` <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg <br /> PKG. TREATMENT PLT. El Capacity—Capacit <br /> Y No. Compartments 4 <br />�r <br /> 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-neareht"____WC_11Foundation _; _ Property Line <br /> -SEEPAGE PITS 1 ) Depth Size 1\16mbor <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS - - 0— -- <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-contractinsignature <br /> permit Io g <br /> certifies the following: "I certify that in the performance of the work for which this it is issued, I shall em <br /> tion laws of--Ca <br /> The <br /> p employ persons subject to workman's compensa- <br /> The applicant f4 call for all re u'ed inspections. Complete drawing on reverse side. <br /> Signed X f q q <br /> tie: Date: <br /> FOR DEPARTMENT USE ONLY <br /> - <br /> Application Accepted by.' �� J <br /> Date �� <br /> �r1''' Area 2-- <br /> Pit or Grout Inspection by - -.Data Final Inspection by <br /> Date 4_2�7..� <br /> Additional Comments: <br /> O Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazeiton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE. <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY <br /> CASH DATE PERMIT ND. <br /> EH+ EH t4-28 IRIV.t/A 51 �5. <br /> t� <br /> F <br />