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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> �( Telephone (209) 466-6781 t <br /> a PERMIT EXPIRES TYEAR"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. T <br /> ? <br /> ,�^- <br /> Job Address /Z k• NJ ,i ,fes-�k /1-/J Z2 City t Lot Size PM <br /> 1 <br /> C/o: 6L,-tip <br /> I4 [ i�/9�✓ es :� ! J� '4�s f <br /> Dwner's Name dressPhone <br /> f ContractorA��"f" _ __- Address ,��f1 GOicense No. ��I� Phone 3Z/ <br /> k TYPE OF WELL/PUMP: ,NEW WEL-L_ P WELL REPLACEMENT ❑ rDESTRUCTION ❑ x <br /> PUMP INSTALLATION, ?j_ ,___� %`,f�YSTF REPAIR ❑ ♦ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC SEWER LIN`E5 � DISPOSAL FLD. � PROP. LINE � <br /> v._ FOUNDATION 7 'AGRICUL•TU ' //RE INEft OTHER WELT PITS/SUMPS f� <br /> INTENDED USE TYPE OF,WELL r:PROBLEM AREA CONSTf# CT 01 WSPECIRCATIONS ` <br /> El Industrial ❑ Open Botta 1� �� C] Mante-Ga� ;Dia of Wall'l'_xcavatidn- _ Dia. of Well Casing <br /> Domestic/Private Gravel Pack {i ; L1 Tracy Type of Casing `� '`' Specifications _/dr7 <br /> 1 <br /> I`1 Public ❑ Other r' --�)[-1 Delta�t ny . ;; Depth of GrouS.eal e ��" Type of Grout w <br /> I I Irrigation /�Apprcx. epth' li I Eastern' Surface:.Sea1'Installe Eby-- -;EWAI I/� �Lls. <br /> t <br /> Repair Work Done ❑ Type of Pur1t «�'-}i----� '` Slate Work Done <br /> P YP A ' <br /> Well Destruction ❑ Well Diameter, Sealing Material Itop 501 `, <br /> Depth ;\ Filler Material (Below 50') <br /> l - <br /> y TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l 1 DESTRUCTION l 1 INo septic system permitted if public sewer is <br /> 6 <br /> available within 200 feet.I <br /> Installation wil Residence Commercial— Other, <br /> Number of living units: tuber of bedrooms <br /> Character of soil to a depth of 3 feet: y 't '` � j Water table depth (� <br /> SEPTIC TANK ❑ Type/,Mfg Capacity—, No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Founda_ + x Properly Line 1 <br /> LEACHING LINE ❑ Nn.'& Length of lines Total len size' <br /> FILTER BED ❑ Di tante to_nearest: Well Foundation Property-Lr <br /> SEEPAGE PITS I I Depth Size Number` 1 <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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, anr <br /> � <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."Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applica li f r allre spections. Complete drawing on revers ide. <br /> I <br /> Signed X Title: Date: <br /> t t FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date r! O Area <br /> r e L' <br /> Pit or Grout Inspecti y r l� Date r� Final Inspection b> Dat ����� <br /> I �ev�ri,sti.},�n 14 rw �v l✓ci� d-S�i't -<< 37 � ts.� w- �r 1►-�. <br /> f Additional Comments: v >r% <br /> ❑ Stk 466-6781 ❑ Lodi 1369-3611' ❑ Manteca 823-7104 ❑ Tracy 835-6385 i <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> j f <br /> FEE tt _ INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. <br /> + EH 13-24(REV.r/µ5) 7 <br /> EH t4-2a .�1 <br /> W �r(� <br />