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f _ <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> k Telephone (209) 466-6781 - <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) r <br /> Application is heieby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> I 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/6 //�f. r�GQ +7 d• City Tr GY Lot Size PM <br /> Owner's Name ! oI)'V 176�� Address Ye�6� '' 1100 Phone <br /> Co ractor r ply '"Address v License No. Phone <br /> T�,PE OF WELL/PUMP: NEW WELL Q WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP 116TALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDPTION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> S INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑,Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> LI Domestic/Private ❑ Gravel Pack Li racy Type of Casing Specifications <br /> [`)-Public ❑ Other.. 1 � [l Delta Depth of Grout Seal Type of Grout <br /> i Ilirrigation .Ap�lrox Depth 1h1 [astern Surface Seal Installed by <br /> I <br /> Repair Work DoK l L3ype of Pump H,P. State Work Done <br /> Gy I g, r • J <br /> Well Destructioh' © 'u 1Vell Diameters rf Sealing Material Itop 501 <br /> s f %ep1h ! f- !� Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: I'NEW INSTALIA'T ON I') REPAIR 1ADDITIONX DESTRUCTION i I (No septic system permitted if public sewer is <br /> ? { available within 200 feet.) <br /> iriMailation willserfve: Resideuce.o Comme=.0_ Other <br /> Number of living runts:— Number of bedrooms <br /> �haracter of soil to a depth of 3eetti 1I?hr /E01,41S9 -fAdW640YAv04 AT/Qf Water table depth �� f <br /> SEPTIC TANK 01 TypkMfg. Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑' Method of Disposal <br /> �r Dist`nce to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑=4No.t Le gth of lines Total length/size <br /> FILTER BED ❑` Distani eAo nearest: Well Foundation Property Line <br /> �SEEPAGE PITS ! 1%��Depth Number f <br /> SUMPS Distance to neaiest: Well '��p Foundation Property Line <br /> DISPOSAL PONDS ❑ - <br /> e^'I hereby certify that I have prepared this application and that Yje work,[,ll be done in accordance with San Joaquin county ordinances, state laws, and <br /> ,'rules and regulations of the San Joaquin Local Health Di§trict. <br /> 1 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.becorite subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> .��Icertifies the following: "I certify that in the perfbrmance of the work for which this permit is issued, I shall employ persons'subject to workman's compensa- <br /> tion' laws of California." <br /> 4 <br /> The applicant mus call for all required inspections. Complete drawing on reverse side. 1 <br /> Signed X 1 Title: Date: 9-°/9'~4?'9 <br /> � t <br /> FOR DEPARTMENT USE ONLY <br /> i r <br /> • Application Accepted by s _p Area <br /> Pit or Grout Inspection by Date Final Inspection by Date f <br /> Additional Comments: <br /> ❑ Sik 466-6781 ❑ Lodi 369-3621 I ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental;Health Permit/Services'1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i FEE <br /> j INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> ♦.EH13-24iREV.I/n5Y C>0,. C 6 (� �! -a35 ] <br /> EH 14-26 - '�'-�� <br />