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APPLICATION FOR PERMIT <br /> c <br /> SAN JOA(IUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209)40 69M +&6—ff Q00 <br /> 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. 1662 for well/pump and the R es andulations of the San Joaquin <br /> Local Health District. .s and <br /> Job AddressCity Loi Size 4r PMfLv��""'- <br /> Owner's Name Address �' / !(11'lleL�' Phone 31 <br /> X- Contractor Address © License Nn.,-t7474y Phone 3 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONS <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK ^-SEWER LINES DISPOSAL FCD._ PROP.-LINE' <br /> FOL"ATION AGRICULTLIREWELL - - -OTHER WELL: - PITS/SUMPS <br /> INTRNDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Indus$ial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Dorhestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F'1 Public n Other F1 Delta Depth of Grout Seal Type of Grout v <br /> I I Irrigation --Approx. Depth I I Eastern Surface`Seal Installed by _. <br /> Repair-Werk--Dene 0 Type of Pump H.P. State Work Done_ <br /> Well Destruction HiQ Well Diameter % Sealing Material (top 501 12 <br /> Depth Filler Material (Below 509,- - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTFjUCTION I 1 (No naptic system permitted if public sewer is <br /> available within.200 feet.) <br /> Installation <br /> �e* <br /> Residence_ Comma 661_ Other <br /> Number of lits. Number of bedrooms t <br /> Character of soil to a depth o t: able depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal N, <br /> Distance to nearest: We F ation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to neares• Well Foundation Property Line <br /> SEEPAGE PITS F I 0$pt Size Number <br /> SUMPS Ll stance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I heAby!*� F 8y that t .: ap�trllsi rr and the work will be done in accordance with Son Jwgtun county�s,stoma IaWs,atxl <br /> rules and�tegu48tions of tl;er5�an Joaquln Lo 4144aatth District. <br /> Home owner or licensod'egent's signature csitifies the following: "I certify that in the performance of the work for which this permit is WK", I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies t4 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 must Calhfor all requi s coons. Complete drawing on reverse side. <br /> Signed X Title: LY(.�rY�.k./`�.� Da c / l • <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by r v `�= - Date Z^ , '��s Area <br /> Pit or Grout Inspection by Date Final lnspaction by., Data <br /> Additional Comments: J �fi2,>�LA.%pP -- - —�� � 1r}t <br /> 18:Stk ❑Lodi 369-3621 ❑ Manteca 84-7104 ?Tralty SS5 6385 � v <br /> Applica et opies to: Environmental Health*ifmiftervices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 'p <br /> ZZ\ k.3 O+FEE n <br /> r <br /> INFO AMOUNT DUE AMOUNT REMITTED CK CAS//H RECEIVED BY DATE PERMIT'NO. 6a" <br /> + EH 13.24 1REY. i e 51ao <br /> EH 14-28 <br />