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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON 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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. z i ® A 7. <br /> 7' ��,s TM 9 J City .�— Lot Siz /2r_ PM <br /> Job Addrer .-5 e'�.-7- -t/! .,; ._.: I, q� /�^ <br /> . .. 2) e17 �" J Phone <br /> Owner's Name _ Address n <br /> ,6, ,� ,�,,� a�3/ : s Phone <br /> Le <br /> Contractor � Address License No. <br /> TYPE OF WELL/PUMP: NEIN 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 WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> -wi <br /> Dia. of Well Casn <br /> ❑ Industria! ❑ Open Bottom <br /> LI — Dia-of--Well-Excavation. g <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> s ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Public��. ❑ Other }, I <br /> ❑ Irrigation <br /> __IApprox.,depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done LlTypedE of Pumps H.P- Sta <br /> te Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth j Fiber Material (Below '( <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION 11 (No septic system permitted'if public sewer is <br /> I .( �I tI\M ,,,a`vaillable within 200 feet.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units:A N.m.ber of a ooms <br /> i ( µrsc� `� Water table depth <br /> Character of soil to a depth of 3 feet:, , <br /> � ,�, ! <br /> SEPTIC TANK E3 hype/Mfg _"Capacity v /No. Colnpartments <br /> PKG. TREATMENT PLT. El <br /> tho&of Disposal� � `_ �C <br /> Distance to nearest: Well Foundation Prop rtYne <br /> { j `2 <br /> .. `�. -Total length/size r <br /> LEACHING LINE L!- No.& Length of lines f. <br /> ,n- . Foundation - rcae�4�1-�w�--- <br /> FILTER BED ❑ Distance. o nearest: Will - <br /> I <br /> r <br /> SEEPAGE PITS B' Depth . f ��p f <br /> Size �P (Number <br /> SUMPS El Distance to nearest: Well f� Foundation Property Line 3or <br /> DISPOSAL PONDS ❑ L <br /> ! hereby certify that I have prepared this application and that the work will be done in accorda with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. work for ch this <br />! Home owner or licensed agent's signature certifies the following: "I certify that inthe <br /> laws California." Contractor's or sr b-cant act issued, <br /> hall not <br /> employ any person in such manner as to become subject to workman's which <br /> this <br /> persons subject to workman's compensa- <br /> certifies the following:"I-certifya hat in the performance of the rk for which this permit is issued,I shall employ <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. Z <br /> Li Et� a e: <br /> f , Ted <br /> t Signed <br /> as v !k FOR D PARTMENT USE ONLY <br /> Date � Area <br /> ,pplF ication Accepted by�~ i <br /> ' Dat Final Inspection by Date/= ' <br /> t or Grout Inspection by " -- , - - J <br /> dditional Comments: <br /> ❑ Stk 466-6781 :1Lodi 3621 ❑ Manteca $237104 t ❑ Tracy 83rr6385 <br /> Applicant- Ret_um all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> /// FEEAMOUNT DUE AMOUNT REMITTED OK RECEIVED BY DATE PERMIT NO. fl <br /> INFO <br /> 1 � <br /> +EH 13-24(REV.1/a 5) �lJ (/,4 P " <br /> EH 14-26 <br />