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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {Complete in Triplicate} r <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 Rgles and Regulations of the San Joaquin <br /> Local Health District. <br /> � yl <br /> +� erg roti � <br /> Job Address p A- 4-� I �v G x City 4e—. A-)Lot Size PM ' <br /> Owner's Name° �✓ IL <br /> DA <br /> La/t�QAddress Phone / r <br /> Contractor-I._" *&� wi. Address a-©03 , 1 Willa t License No Phone 0 <br /> TYPE OF WELL/PUMP: NEW WE WELL REPLACEMENT ❑ DESTRUCTION ❑ V <br /> PUMP INSTALLATION SYSTEM REPAIR _❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK f SEWER LINES DISPOSAL FLD. . PROP. LINE { <br /> FOUNDATION g AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial (-]-Open-Bottom�-�.__❑-Manteca ADia. of Well Excavation Dia. of Well Casing 1 'a <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingV r,.r �' Specifications [' <br /> ❑ Public El Other ❑ Delta Depth of Grout Seal ` `? - r Type of Grout <br /> ❑ Irrigation --Approx. Depth Eastern Surface Seal Installed by <br /> Repair Work Done )( Type of Pump �" H.P._I State Work Done t, two <br /> Well Destruction ❑ Well Diameter CA.. Sealing Material (top 501h '' <br /> Depth Filler Material (Below 50'1 ""� � —L <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Cl (No septic system permitted if,public sewer is <br /> available within 200 feet.) ' 1� <br /> Installation will serve: Residence— Commercial_ Other �� ��_"y �/. <br /> Number of living units: Number of bedrooms ; k '� <br /> Character of soil to a depth of 3 feet: t� r <br /> aV , <br /> SEPTIC TANK (/ \❑,.tT,ype/Mfg s # Capaciiy �No.VCompartmen s <br /> PKG. TREATMENT PLT. ❑ —Method of Disposal T <br /> --Distance•to•nearest:­Well - -" Foundation 'Property-Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ElDistance to nearest: Well Foundation Property"Line 3 `'z `_ „4� <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distarice to.nearest:� VsWell- �". Foundation Property Ling <br /> F-1 _� y'� <br /> DISPOSAL PONDS 1 <br /> herebycern that l have prepared this application and that the work will be done in'accordance with San Joaquin scounty tlo�dinances, state laws, and <br /> certify p P PP <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 shall not <br /> employ any person in such manner as to become subject to workman's compensation flaws 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 applican t call for all r ed " coons. Complete drawing on reverse side. <br /> Signed Title: .C4ADate: <br /> ey <br />` FOR DEPARTMENT USE ONLY <br /> Application Accepted by ' Date 2 ArIpa <br /> Pit or Grout Inspection by Date Final Inspection by' Date_ � <br /> i <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy $35-6365 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201. <br /> I' <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO,-A <br /> INFO /,y� GASH - <br /> c� " `L 0 'r <br /> +EH 13-241REV.5/951. (Ig-(3S s�� 1� ,)q6l LK-9 .r O <br /> EH 14-26 - n ' <br />