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d, <br /> l � e <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �N 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is.heleby 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 Ordiriance,No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> 160 f? 12 () <br /> Job Address [ ,, •� - City Lot Size PM <br /> Owner's Name � ^ r f uL 1AV Address atm�� 1 Phone <br /> CA(&11e i License .g 39Phone 52,2 <br /> Contractor =Address U '� No, <br /> TYPE OF WELL/PUMP: INEII WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ l� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL�L-D. PROP. LINE <br /> fOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF.WELL PROBLEM AREA :, CONSTRUCTION SPECIFICATIONS g <br /> ❑ Industrial ❑ Open Bottom•' ❑ Manteca Dia. of Well Excavation ` Dia:r"of Well Casing <br /> C3 Domestic/Private 171T <br /> Gravel Pack ❑ racy : Type of Casing ^� � gSpecifications <br /> f 1 Public ❑ Other l l Delta Depth of,Grout Seal, - Type of Grout <br /> I Irrigation" " _..Approx..Depth { ]'Eastern Surface Seal installed by <br /> Repair Work Done ❑ .Type of Pump H.P. � ''State Work Done T Well Destruction,' ❑ Wed6a�neter Seal ing,Material (top 561 <br /> Depth Filler Material (Belo 50,)% <br /> :TYPE-GF-SEPTIC-WORK-, . NEW--INSTALLATION f 1REPAIR/ADDITION DESTRUCTION (No septic system permitted if public sewer is (6� <br /> i. �.... ,�,av6ilable_within.200-feet-.)-------- <br /> Installation <br /> .Installation will serve: Residence Comrrlerciat_ Other <br /> I Number of living units:' Number of be ooms <br /> '''Character of soil to a depih,of_3,leet: Water table depth <br /> SEPTIC TANK ❑ TypelMfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ t Method of Disposal . <br /> ``rb ., Distance to nearest: Welles Foundation Property-Line. <br /> LEACHING LINE No. & Length of lines u _ T Total-length/size( ' <br /> FILTER BED LJ Distance to nearest: Well� 1 Foundation Property Line i{ <br /> SEEPAGE PITS t-'1 • Depth r Size Number , <br /> SUMPS L1 Distence,to nearest: Well Foundation Property Line <br /> I DISPOSAL PONDS 0 # <br /> I hereby.certify tltiat I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, <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.ofJhe work for which this permit is issued, I shall not <br /> employ- n <br /> y person in such-manner as to become subject to workmans compensation laws of California." Contractor's hiring or sub-contracting signature a� <br /> certifies the following: '9 certify,that in the ormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws,of California." i C <br /> Th'_applicant ll for all re fired ins ctigns. Complete drawing on revir§e side. "' a <br /> Signed X -!' _ Title: Date: d� <br /> ` FOR DEPARTMENT USE ONLY <br /> Application Accepted by �i_� �(T). - .Date---- -- �"'�` Area 0 <br /> Pit or Grout inspection by Date .• Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑'L 1 369-3621 © Manteca 823 7104 O Tracy 835-6385 <br /> e Applicant- Return all copies to: Environmental:Health Permit/Services-1601 Es Hazelton Ave., P.O. Boz 2009, Stk., CA 95201 ��\rt`�` <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> 7 1Z1 <br /> + EH 13-24(REV.t i x 51 (y�-.�] `/J <br /> ! EH 14-26 <br /> 1 <br />