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APPLICATION FOR PERMIT <br /> ` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON 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 welt/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address t? O0 L _ �._�� City Lot Size_ v PM <br /> (' <br /> Owner's Name .J �(�� _ Address Phone <br /> 127y 22- <br /> Contractor dress f� /y �G��°4 _ License No'T J Phone V J <br /> q TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> i - <br /> PUMP INSTALLATION ❑ SY TEM REPAIR L1 OTHER ❑ <br /> a DISTANCE TO NEAREST: SEPTIC TANK SEWER LIN DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULT E WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ARE C STRUCTION SPECIFICATIONS <br /> 11 Industrial ❑ Open Bottom 171 Manteca Dia. of Weil xcavation Dia. of Well Casing <br /> l ❑ Domestic/Private 171 Gravel Pack El Tracy Type If . <br /> sing Specifications <br /> FI Public Cl Other ❑ Delta ADeptoISGrout Seal Typeof GroutI I Irrigation ,Approx. Depth I ] Eastern al Installed by <br /> Repair Work Done O Type of Pump H.P. State Work Done r <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE-OF-SEPTIC WORK: NEW INSTALLATION REPAIR! DITION I I DESTRUCTION ( I (No septic system permitted if public sewer is <br /> r+[ availabl within 200 feet:) -- <br /> Installation will serve: Residence_ Commercial__ Otherwyt' 1 .3 .lL�� 71 <br /> Number of living units: Number of bedrooms <br /> F Character of soil to a depth of 3 feet: � Water table depth <br /> SEPTIC TANK ❑ Type/Mfg F CapacityNo. Compartments <br /> PKG. TREATMENT PLT. ❑ r ��:': Method isposal <br /> F Distance to nearest: Well Foundation Property.Line U V r <br /> LEACHING LINE ❑ No. & Length of lines Z , Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation 7 Property Line <br /> F Xor— <br /> f <br /> SEEPAGE PITS l I Depth 2 57— Size Number---'vI <br /> SUMPS Cl Distance to nearest: Well l.moi Foundation Property-Line­� <br /> DISPOSAL PONDS ❑ <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, an <br /> rules and regulations of the San Joaquin Local Health District. <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 shalF.010-1 <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." <br /> The applica must calf for required nspections. Complete drawing on reverse side. t <br /> " t <br /> f Signed XAnIl Title: _Q:f� Date: ' <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 21' Area+ <br /> 1'7a <br /> Pi or Grout Inspection.by Date Final Inspection by ate!7 <br /> Additional Comments: 4�eLg <br /> 11Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1821-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1�\' <br /> INFOEEE AMOUNT DUE AMOUNT REMITTED CASK RECEIVED BY DATE PERMIT'NO. <br /> •f.EH 13-24IAEV.i/R5) ✓�•! <br /> � J/ 1 <br /> EH 14-26 { 4 (�� ✓1 <br />