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_r- <br /> �' �` APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> I 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- 1W2 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. 01 <br /> Job Address City �M1{ I_ Lot Size L" PM <br /> 7 7-0 <br /> Owner's Name � JL/��dress _ Phone I <br /> 1I ( Q <br /> Contractor P. dress _License No. . Phone <br /> T12 <br /> YP WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION 177 SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEP SEWER LINES DISPOSAL FLO. _ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL _— PITS/SUMPS 1 <br /> 1 <br /> INTENDED USE TYPE OF WELL PROBLEM AR ONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. o Excavation Dia. of Well Casing <br /> ' ❑ Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seat Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter _ Sealing Material(top 501 <br /> Depth ` Filter Material i8elow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> `available-within 200 feet.) <br /> Installation will serve: .Residence! Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to-a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg _ Capacity 1/l/ No. Compartments <br /> _. <br /> PKG. TREATMENT PLT.❑ / U Method of Dispos 1 <br /> Distance to nearest Well I_e y <br /> Foundation Property Line�yc <br /> LEACHING LINE No. & Length of lines _'� _ Total length/size. <br /> FILTER BED ❑ pistance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS epth ALL._ l'1 Size _ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation _�.Q�_ 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,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 workmen's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> 1 certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workmen's compel- - <br /> tion laws of California." <br /> The applicant m st fora required inspections. Co pie a drawing on rglrer�e side. <br /> Signed X l /U-w Title: ---(�//y{�(/n Date: I I <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by — — Date /-4 715' fff- Area 0� - <br /> _e2e �6 <br /> or rout Inspection by 6 Date ('Final Inspection by <br /> Additional Comments: /� /L� J�46 %�lc.�_ B dd i <br /> ❑ Stk 466-6781 ❑ Lodi 369-3H21 Manteca 823-7104 Ll Tracy <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazetton Ave„ P.O. Box 2M, Stk., CA 9=1 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> 1� <br /> EH 14-21"Ev.i,a 5r `7O OQ �5 p� 10 <br /> EH 142E / <br />