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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> f� (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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 4>C 0 //G�� PM <br /> Cit Lot Size <br /> Owner's Name llezg�l +� Address Phone <br /> Contractors 15:�/ I ff 4=Atidres's249-lng-;I�k.--5e'er_ Licen3e—Ntr­ <br /> <P hone---- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑� DESTRUCTION ❑ _ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:,SEPTIC TANK: SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER ELL PETS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA IONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing <br /> 0 omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ! Specifications <br /> ` J u4lic 17 Other ❑ Delta Depth of Grout Seal \r i,!Type of Grout _ I <br /> ! frhlrrigation --Approx. Depth I i Eastern Surface Seal Installed by _ <br /> Re it Work Done ❑ Type of Pump H.P. State Work pone �� 1 <br /> We IMstruction ❑ Well Diameter Sealing Material (top 50') <br /> 3 " Depth Filler Material {Below 501 <br /> �TY IE',OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION DESTRUCTION I 1 No septic system permitted if public sewer)is <br /> NI � �vailable within 200 feet.) <br /> installation will serve: Residence Commercial <br /> Number of living units: Number of bed r oms I <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg } Capacity No. Compartments <br /> P KG. TREATMENT PLT. ❑ ( Method of Disposal r <br /> f <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE LINE ❑ Na. ✓it Length of Eines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> 4 v, <br /> SEEPAGE PITS I 1 Depth _ZZ-5 Size - J Nymber �_,_ .__ <br /> SUMPSDistance to nearest: W Foundation Property Line __Z0 <br /> DISPOSAL PONDS ❑ I i <br /> I,hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin conntj <br /> ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. fJa <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of a work�fgr which tipermit is issued, 1 shall not 10 <br /> employ any person in such manner as to become subject to workman's compensation laws of Califofn Con'tra'tor'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;Alsh II employ p rsons subject to workman's compensa- <br /> tion laws of California." 4 t ; <br /> The applicant st all for aif squire ctions. Complete drawing on reverse side. <br /> Signed X Title: `� Dat ' <br /> FOR DEPARTMENT USE ONLY <br /> �s✓ <br /> Application Accepted by Date r �� } Area 1 <br /> tt�� J i 7 <br /> Pit or Grout Inspection b Date Final inspection by`J Date74� <br /> Additional Comments: i <br /> L7 Stk/ 46626781 ❑ Lodi 369-3621 1 ❑ Manteca 623-7104 ❑ Tracy 835-6385 <br /> Applicant YR®turn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. BoxStk., A 95201 <br /> 1 � 20t1�_ <br /> ?, FEE <br /> tt77II INFO_ n - _ _�REIE©-8YCT.pu& AMB1NT-RMPERMITNO.� � <br /> + <br /> 77 EH 13211REV/r/H5] <br /> EH 14-28 l;l\ I� \ /` <br /> { L] �r 4 <br /> k <br /> t <br />