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H_ APPLICATION FOR PERMIT <br /> SAN 3OAQLIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 465-6781 <br /> DATE ISSUSU <br /> ES­ J6-,-7-T3 oL) <br /> PERMIT EXPIRES I 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 instalf-the`work herein `�' <br /> described. This application is made in compliance with San JoaquinC-County Ordinance No. 549 for sewage or No. 1862 for well/pump 1 <br /> and the Rules and Regulations of the San Joaquin Local Health District. '7� <br /> ,Job Address X47 f,4 Mo �/p - T Subdivision Name 6l>i -0 C; y -),N7 <br /> Owner's Name Pp�T Address/ y PhonegQs� fS'*�7 <br /> Contractor's Name -5 <br /> License No. PhonelDLsCl� <br /> TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT ❑ DESTRUCTION ❑ �` <br /> ti 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> } _ � <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> + "INTENDED USE TYPL OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t <br /> Industrial- `❑'Open ❑-Man <br /> Sottvm teca Dia. ofeTh'Excavation <br /> ❑ Domestic/Private ❑ Gravel Pack ❑{ Tracy Dia, of Well Casing <br /> i Pdblic Other Delta w <br /> # ❑ ❑ ❑ Type of Casing <br /> Irrigation A rox. Eastern { <br /> 9 Depth ❑ specifications <br /> ' Depth <br /> ❑Cathodic Protection <br /> - -- _� Depth;af_Grout.5ea.1 -- : <br /> ❑Geophysical r �.-..... .. ..Type of"Grout <br /> [J Other fi Surface Seal Installed by <br /> �i , y: ` <br /> Repai `Wvrk Done El 'Typef Pump <br /> D H.P. State Work Done <br /> 3 1 v� o - <br /> Well Destruction ❑ WeLlhDiameter� Sealing Material (top 501) <br /> ! Depths ' ,Y + Filler Material (Below 50') s r' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION F1REPAIR/ADDITION )< (No septic tank or seepage pit permitted,if public sewer is <br /> I available within 200, feet,) <br /> -" Installation will serve: Residence Commercial x Other­,!!�Aas4rf <br /> Number of living units: Number of bedrooms 35 - Lot size <br /> �1 <br /> 1Water table depth <br /> Character of sail to a depth of 3 feet: ���� _ . <br /> f 5EPi4C TANK U. Type/Mfg �� > Capacity No. CompartmU ents r <br /> ' 1 PKG..wTREATMENT PLT. ❑ Type/Mfg '`µI Capacity Method of, Disposal <br /> } SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line ' <br /> DESTRUCTION <br /> r LEACHING LINE [J No. & Length of lines -+ Total length/size `- r <br /> Distance tolnearest: Well . Foundation 1 Property Line <br /> PILFER'' BED ;. <br /> f SEEPAGE PITS Depth `� .��., Si`e `��® Numbe <br /> _ ��'�; <br /> F ; EY10— <br /> $UMP-S'�. Oi.s.tance=to Foundation ,___ `roper y Line F <br /> I DISPOSAI PONDS - <br /> rA <br /> k I hereby certify that;I have prepared this application and that the work will be done in-,acco dance with San Joaquin county <br /> ordinances, "state laA, and 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 <br /> permit is issued,,,I. shall not employ any person in such manner-as.to become subject to workman5 compensat•i•on,laws of C,alifornia." <br /> Contractor's h' `ing" yr sub-contracting signature certifies the folloawing:"'I certify'that�in the-perfo�inance_of the work-#or which <br /> this permit �ssued, 1 shall employ person subject to workman's compensation laws-"of California." <br /> The applic call f all re ed sp cti S. Complet drawl n reverse side.' <br /> Signed <br /> FO D PARTMENT USE ONLY {' <br /> Application Accepted Area SLk 466-6781 <br /> { <br /> Additional Comments: 1 F 0Lary-f, On ❑ Lodi 369-3621 <br /> r 1 ! Manteca 823-7104 <br /> Pit or Grout Inspection by r�~Z2- ate *� ❑ a <br /> k _.-�K--., _-.t- _ _ ©ate��(�F r}i�'� ❑-- racyT-835-6385 <br /> M Final Inspection by T `__ T <br /> t Applicant � o: <br /> Return all copies t . Environmental Health Permit/Services 1601 E. Hazelton Ave P-.0. Box 2069, Stk., CA 95201 <br /> F FEE A' Lg�� <br /> AMOUNT REMITTEDRECEIVED BY DRTE PERMIT N0. <br /> INFONP <br /> �..�_ � ,,_ Y'- 10182 500 <br /> EH 13-24 REV <br /> 14_26 . <br /> I "`•��_-� <br /> - <br />