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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA i <br /> ._ Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> ,,F-.iGomplete in Triplicate) <br /> ,/t <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. a f�Q-2-50-3 j` <br /> Job Address ity _ Lot Size �G��� PM <br /> Owner's Nam 5 �� � Address / 1 i+i%A1 - t Phone <br /> Contractor �'F �_ Address d r 0, 'f <br /> License No. C '" _� Phone <br /> TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> .._PUMP-1NSTALLATIONvO;----­Y :.-SYSTEM-REPAIR-L] v OTHER El I <br /> 'I <br /> 4 DISTANCE TO NEAREST..:SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I� i <br /> INTENDED USE TYPE OF.INELL PROBLEM AREA CONSTFIUCTION SPECIF1CATt6NS���' <br /> D Industrial ❑ O en'Bot[om ❑ Manfeca, Dia. of';WeExcavation Dia. of Well Casing v f <br /> Ll Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1-1 Public ❑ Other Cl Delta depth of Grout Seal -- Type of Grout <br /> ` 1 1 Irrigation ' _..Approx., Depth ! I Eastern Surface Seal Installed by <br /> Repair Work Done 13 Type of Pump H.P. State Work Done _ <br /> Well Destruction El Well Diameter Sealing Material [top 501 r• z, 1.. 1 I, <br /> Depth Filler Material IBelow 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION^ REPAIR/ADDITION ! I DESTRUCTION I 1 INo septic system permitted+if public sewer is <br /> available within-200 feet.► <br /> a Installation will serve ResidJ_c6mmercial- Other �. <br /> lR Number of living units: � ,.. Number"ofibe ooms <br /> Character of soil to a depth of 3 feet: Water table depth—. fo*C <br /> SEPTIC TANK Type/Mfg _` "'Capacity..,, No. Compartments —�� <br /> PKG. TREATMENT PLT. ❑ a r� - <br /> . :, ► <br /> ' <br /> ,A � � �,,� ;,� tl�i,� ,�; ;�r:. . ! Method of Disposal pi <br /> Distance to nearest:­—Well neZio, Foundation rye Property Line <br /> 't ' ! 11 <br /> G <br /> LEACHING 1 <br /> LINE No: '&.Length of lines Q Total length/size 0' X � IM <br /> " ..FILTER BED ❑, ' Distance to nearest: Welty° Foundation f Property Line __- <br /> ' I , <br /> SEEPAGE PITS F.) Depth I Size. Number I� <br /> SUMPS LI' Distance to nearest: Well Foundation Property Line ' I� <br /> DISPOSAL PONDS ❑ r ; <br /> I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, ani,,, <br /> rules and regulations of the San Joaquin Local Health District. �� s <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 notPf <br /> ,..,. <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,1 shall employ persons subject to workman's compensa-t <br /> tion laws of California." k ! = <br /> The applicant must call for all required ections, Complete drawing'on•reverse slid <br /> Signed X Title: <br /> .., _ Date: 1-7-T �r'�4 <br /> ,FOR-DEPARTMENT USE ONLY I - <br /> Application Accepted by ,�� E <br /> Date Area ; <br /> p <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: - <br /> ❑ Stk 466-6781 ❑ Lodi -3621 O Manteca 623 7104 ❑ Tracy 835-6385 it <br /> Applicant - Return all copies to: Environrnentat Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE <br /> INFO PERMIT'NO, <br /> EH 11CASH I <br /> +. 3 24 1REy.1/i 57 {f l{/�! <br /> EH <br /> 126 / d(EY 7Vi t'rf I , <br />