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APPLICATION FOR PERMIT • <br /> SAN JOAQUIN LOCAZ HEATH DISTRICT <br /> 1601 E. HAZELTON 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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. (— G <br /> Job Address `0 2�Afes^ 44L-LO cd +'•�• �1� City Lot Size PM <br /> Owner's Name Address a'" AVElle LK Phone 57-033 t <br /> A.t GNO CO RDOU R <br /> Contractor iVre(� U &IA RntCOC:&Address 01, � I�Frt •-�flc�License No. Pholkbf <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION�❑,y� <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLDPROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WEA_yY gra PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑iPomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION 71 (No septic system permitted H public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 have prepared this application 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 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 laws of California."Contractors 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 applicant must callforall required inspections. Complete drawing- verse;ide.n v <br /> Signed x' 4-' DrL)1 L_O('7 AA.E N z Title: � C Date: 10 <br /> / J�/. <br /> FOR DEPARTMENT USE ONLY <br /> Application Accept bed y/�;' //t Date �.d� Area <br /> Pit or Grout Inspe ' y Data Final Inspection by Date <br /> Additional Comments: /Kl-e_c_ t2-�-Q !riZC4lL�YYdirc �cl2�S �/v_/yS <br /> ❑ Stk 466-6781 ❑Lodi 359-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385Gtta�� t <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201/ <br /> V17 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. L� <br /> INFO t /' <br /> + EH 13211REV.1/85 <br /> EH 1428 G •�/� •5 47J9 <br /> 0 <br />