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1 u � <br /> APPLICATION FOR PERMIT <br /> ' SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> r <br /> ' Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 <br /> (Complete in Triplicate) j <br /> ' AppliceYon is hereby made to the San Joaquin Local Heahh Disvict for a permit to conatwcl arW or install the work"re,n described, Th;s application is s <br /> made In compliance with San Joaquin County Ordinance No.648 for sewage or No. 1662 for Well/pump and the Rules and Rcgolalions of the San Joaquin <br /> Local Health District. <br /> Job Address �_�J15�22•�'e _. _ City LCC^^C .oi Sita_ L7. M <br /> Owner's Name J4 �/�r a"'•( 12��9dress Sw --- ._ Phone..,�-7�sz <br /> Contractor's Nacre ji. License No. ,___ Pion —. <br /> TYPE OF WELLIPUMP: NEW WELL 0 WELL REPLACEMENT O DESTRUCTION 0 <br /> PUMP INSTAUJITION Cl SYSTEM REPAIR O OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE —. <br /> FOUNDATION f. AGRICULTURE WELL - OTHER WELL PRS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 0 Open Bottom O Manteca Dia. o1 well Excavation - Dia.of WON Casing <br /> 0 Domestic/Private 3 Gravel Pack Cl Tracy Type of Casing, ' - SpeciRdaBons <br /> 0 Public O Other C Delta Depth of Grout Seal Type of Grout <br /> 0 trrigafon _Jrpproz. Depth 0 Eastern Surface Seal Installed tly 6 <br /> Repair Work Done 0 Type of Pump H.P., State Work Dora t <br /> Well Destrvcton r Ft Well Diameter $ealing,Metorial Rog,60'1 1 <br /> Depth _ Filler Material (Below 60) <br /> n <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION C^ REPAIR/A001110 k DESTRUCTION 0 INp septic system' permitted itpubpublicsewur is♦ "avaNabk wiFile <br /> Within 200(esti aft <br /> Installation Will serve: Residence✓ Commerciat_ Oder <br /> Number of 4ving units,j__ Number <br /> Character of sol to a depth of 3 feet:_ .___-_ ` Water table depth TW _. N <br /> SEPTIC TANK Type/Mtg _. ._ ..._ Capacity No. Compartments <br /> PKG. TREATMENT PLT. - Method of Depose' A <br /> D,suance to nearest: Well �} FotaMation Ropetty line 1 f <br /> ` LEACHING LINE 15r No. 8 Length of lines ' / .t L 'Total length/size <br /> FILTER BED C Dalance to noarest: Wall AW:'- ltcuL dation Roporty Line <br /> 1 <br /> SEEPAGE PRS i Depth --= Sjze.�.._— - L Number. <br /> SUMPS Distance to nearest Well Foundation' __ Property Lire_ <br /> DISPOSAL PONDS ' ' I <br /> I hereby certify that I have prepared th,s apPlicaGon and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I oardty0tit In the podormamto or the work for which this permit's issued, I shall not I <br /> employ any Person in such manner as to become subject to workman's compensation laws of Cahfomia"Convectors hiring or subcontracting signewre <br /> certifies the following:"t certify that in the perfarmance of the work for which this porrrvt is issued,I shell employ persons subject to workman's compenaa- i <br /> tion laws of Califomis.- <br /> i <br /> The app' nt m t call for aY inspections. C to drawing on <br /> Signed ---. <br /> l 1 r FOR DEPARTMENT USE ONLY r <br /> 09 <br /> APP'.Icatbn Accepted by ��.`.t -- .-----__T_ Date Area <br /> Pit or Grout Inspection by ..... _..___ Date._ Final Inspection by_ _ _ Date ?l <br /> Additional Comments: _ <br /> R Stk A66-67(31 C Lodi 369-3621 ❑ Manteca 823-7104 Cl Tracy 835-6385 <br /> Applicart . Return all copies to: Environmental Health Parmn/Services 1801 E.,Hstahon Ave., P.O. Box 2009, Stk., CA 96MI <br /> ' FEE AMOUNT DUE AMOUNT REMITfEO H RECEIVED BY DATE PERMIT'NO <br /> INFO <br /> 1 . H11371 Rw •D:tn,' I S ZSrEc1 I%�85 ISS 1 13 n J l� <br /> to 1416 <br />