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F <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> L"6/ <br /> Job Address _��� v '� _�-- � � _ City gra/ Lot Size PM <br /> Owner's Name ✓L19 P1 1 N_ Address 6-2 �— Phone <br /> Contractor z/-C-12 Address /W e4 License No f Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ � .�,.SYSTEM-REPAIR.Lp, - ` rr OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES w- DISPOSAL FID. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications" <br /> i <br /> 11 Public ❑ Other CI Delta Depth of Grout Seal Type of Grout _ �- <br /> I I Irrigation --Approx. Depth i 1 Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump `��' 'H.f% State Work Done�_L r a <br /> - 3=�, <br /> UVetE�struction❑ "'WeII Diarrieter SealFng 11Aaterial flop 50'1 <br /> Depth Filler Material (Below 50'1 v <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [.] REPAIR/ADDITION L I DESTRUCTION INo septic system permitted if public sewer is <br /> { i available within 200 feet.) t E <br /> Installation will serve: ResidenceCommercial_ Other'—­- <br /> Number <br /> ther"Number of living units: Number of bedrooms <br /> j Character of soil to a depth of 3 feet: I Water table depth { <br /> SEPTIC TANK ❑ Type/Mfg r* Capacity No. Compartments s l t} <br /> PKG. TREATMENT PLT. ❑ t Method of Disposal <br />' Distance to nearest: Well .Foundation I Property Line C <br /> LEACHING LINE 1 ❑ No. & Length of lines Total length/size <br /> FILTER BED_ s ❑ Distance to nearest: Well f Foundation Property Line <br /> �t } <br /> SEEPAGE PITS it Depth - Size''"•_l_ __ ' Number <br /> SUMPS 0 Distance to nearest 9 Well $Foundation I Property Line ) <br /> DISPOSAL PONDS ❑ fY r > <br /> I hereby certify that I Nave 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. 5 , <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."Contractor's 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. I r <br /> The applicant must Z;!5 <br /> ed inspections. Complete drawing on reverse side. i <br /> r _ <br /> Signed X' •,Title: t pate: <br /> � <br /> J FOR DEPARTMENT USE ONLY <br /> Application Accepted by e-� ' ` ` Dr�ate r y Area <br /> j <br /> Pit or Grout Inspection by Date Final Inspectiont by Da e� _ <br /> E } F <br /> Additional Comments:* + 4 <br /> ❑ Stk 466-6781 1❑ Lodi -3621 ❑ Manteca 523-7104 ❑ Tracy 635-685 <br />` _,.Applipant__Return„all piesto:.)= yirgntnenial_Health•Perplit/.Seryices,1601_E.Jiazelton..Ave. f?.O. Box.2009,,.5tk., GA 95201.”-_.._ <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY OATEN PERMIT NO. <br /> +.EN . IREV.1i851 <br /> EH142e <br />