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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 4+ <br /> 1601 E. HAZELTON AVE.,.STOCKTON, CA <br /> Telephone (209)'466-6781 <br /> I PERMIT EXPIRES 1 YEAR FROM DATE ISSUE D <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 /> Job Address ' <br /> City 46 Lot Size pM <br /> Owner's Name ZVA, l-1LZ_"4.L r �J Address �( ,� <p�(�„ :3 Y <br /> Phone~ �8 <br /> Contractor c WL �. <br /> Y�Addrass `License NoZP_ �Sy:Ph"one .- <br /> TYPE OF WELL/PUMPP NEW WELL ❑ � WELL REPLACEMENT ❑ DESTRUCTION❑w <br /> } <br /> i 31a 3 PUMP INSTALLATION ❑ 4"` SYSTEM'REPAIR ❑ OTHER W❑ f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSA D. PROP. LINE ! <br /> ( FOUNDATION AGRICULTURE WELL 9.T44 WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom "s ' ❑ Manteca Dia. ell Excavation F <br /> Ria. of Well Casing �f <br /> I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casing4 <br /> Specifications/ <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal <br /> F p !!t� Type of Gro t <br /> ❑ {rri ation y* <br /> 9 —Approx. Depth f7�Eastern SurFace Seal Installed by <br /> Repair Work Done ❑ Type of Pump H-P. �� _A State Work Done <br /> Wel! Destruction ❑ Well Diameter Sealing Material Itop 50'I ,.. { <br /> [ n� <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC:WORK: NEW INSTALLATION ❑: REPAIR/ADDITION DESTRUCTION (Vo septic system permitted if public sewer is <br /> available within 200 f4t.) C - <br /> Installation will serve: Residence 4 Commercials_ ..Othei " /7 <br /> Number of living units: 1L_ Numbertof bedrooms_-3—� - <br /> Character of soil to a depth of 3 feet: I '-,\' 1 t % <br /> 4 - Water table depth , M <br /> SEPTIC TANK Type/Mfg ('' ` capacity <br /> f f" <br /> p Y No. Compartments <br /> PKG, TREATMENT PLT. ❑ _� w �.� Method of Disposal <br /> : .Distance,to riearest V41ell - "Foundation� Property Line r� <br /> i LEACHING LINE JNo. & Le g4,wfines Total length/size d <br /> FILTER BED } ❑ Distance to nearest: Well V� Foundation �_ property Line <br /> {. <br /> l / . <br /> SEEPAGE PITS # Depth i �wZ57 Size - -" Number, 4 !615 i. <br /> SUMPS ❑ ,.Distance to nearest: Well © 4 <br /> Q Foundation !! <br /> Y =Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and tRat..the work will be done in accordande with San Joaquin county ordinances, state laws, and er 1 <br /> rules and regulations of the San Joaqdin Local health District: F t <br /> Home owner or licensed agent's signature certifies the following: I.certiify 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 /> I 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." <br /> The applicant must call for all equired inspec' s. Complete drawing on reverse side, <br /> k <br /> t Signed f <br /> Title: Date: <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> &dditi..,l <br /> cation Accepted by Date 1 AreaGrout Ins tion by Date ' •`� Final Inspection b !fid Date 2"1 Com — Q Z 0 <br /> ❑ Stk 466-678 ❑ Lodi 369-3621- ❑ Manteca 823-7104 .. ElTracy_635-6385 - Y <br /> Applicant-Ratum all copies to ✓nvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMIT7EQv CASH RECEIVED,BY DATE PERMIT*NO. <br /> I` + EH 1428 1REV.i/A 51 O `' <br />