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E. <br /> APPLICATION-FOR.PERMIT <br /> SAN JOAQU111i L®CAL HEALTH DISTRICT <br /> 1601 E. HAZES T ON,AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES�1'YEAR FROM DATE <br /> 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. 1962 for well/pump and the Rules and Regulations:of the San Joaquin <br /> Local Health District. <br /> Job Address -57 <br /> ddress � p 1 C F��+�' ; <br /> �-� Y ' a <br /> Er CitY,. >� Lot Size,_ PM <br /> Owner's Name + 1'�Fy Address '.Phone <br /> Contractor's Name L E— LZAASt 11icense No. r 'F� fi ", Phone <br /> TYPE OF WELL/PUMP: NEW WELD ❑ WELL REPLACEMENT ❑ DESTRUCTION-0. <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR E 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 CONSTRUCTIOPV SPCIFICATIONS` """ <br /> ❑ Industrial ❑ Ope n Bottom ClMantece" _ Dia. of Well Excavation bio. of Well Casing <br /> -W <br /> ❑ Domestic/Private 0 Gravel Pack` ,❑ Tracy T Type of Casing _* ; / .k +i j Specifications <br /> ❑ Public ❑ Other t i ❑ Delta• *Ni Depth of Grout Seal ' <br /> .� P t •� � � •"Type of-Grout <br /> El Irrigation �Approx.Depth+ .❑ Eastern 5ufface Seal Installed by." <br /> . *#!-. .I ' <br /> Repair Work Done ❑ Type of Pumps �'3 i fHflP i y^"` State Work.bone"*'V I ; <br /> Well-Destruction ❑ Well Diameter <br /> Sealing Material (topl�s,.). <br /> ;JDepth �}. Filler Materia !I Below 50') 4 <br /> TYPE OF SEPTIC WORK_: NEW INSTALLATION ❑a REPAIR/ADDITION ❑ DESTRUCTION-0,INoseptic system permitted if public sewer is <br /> ava)lable within 200 feet.) <br /> Installation will serve: Residence- LeCommercial <br /> Number of living units: Number of bedrooms <br /> � o <br /> Character of soil to a depth of 3,feet: } Water table depth <br /> SEPTIC TANK E] Type/Mfg. r Capacity No. Compartmentsa <br /> E <br /> PK'G!TREATMENT PLT. El .J = -� M 1, � ethod of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> k LEACHING LINE ❑ No. & Length of lines , Total length/size <br /> F , FILTER BED ❑ Distapce"to, nearest: Well Foundation Property Line <br /> _ A <br /> t SEEPAGE PITS Depth Size c�Number <br /> SUMPS ❑ Distance to nearest: Welh � Foundation' 41 Property Line <br /> DISPOSAL PONDS ❑ t <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. I _:f J <br /> Hbrne 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 /> cert'' the following: Certify that int a performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion la f C Irfornia. s <br /> The a,pplican call fol II r uired pecti plete drawing on reverse side. (� o <br /> .' <br /> Signed Title: D,t,: U <br /> 1 FOR DEPARTMENT USE ONLY <br /> t j <br /> Application Accepted by Date [ Area <br /> Pit or Grout Inspection by Date *D9 <br /> Final Inspection by <br /> Additional Comments: leyj <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 t , <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA'.95201 <br /> Y I / <br /> FEE AMOUNT DUE�''6 AMOUNT REMITTED RECEIVED BY DATE Y <br /> INFO CASH PERMIT'No. p <br /> + EH 13-24 MEV,101831 <br /> EH 1426 <br />