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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH 'DISTRICT <br /> 1641 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (2091466-Mi <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> h (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 R <br /> Local Health District. s` es and of the San J oaquin <br /> f i , <br /> 3 Z.$~ T <br /> Job Address City Lot Size PM i <br /> 'tie s �+ _�- <br /> Owner's Name . Address `Z Z 54 1 cervr <br /> i Pi►one�707 42z-�b8$ <br /> I! � 'CCA g 4 53 <br /> Contractor dress f -cense No.. $33 2(v Phone -2 <br /> TYPE OF WELL/PUMP: I Av NEW WELL;I WELL REPLACEMENT ❑ DESTRUCTION ❑ VU <br /> PUMP INSTALLATION{E] SYSTEM REPAIR ❑ OTHER ❑ r\ <br /> DISTANCE TO NEAREST: SEPTIC TANK ;I SEWER LINES DISPOSAL FLD. PROP. LINE <br /> See- -fiv re. CO C-1. FOUNDATION AGRICULTURE WELL U I HER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ff zn 1 <br /> pe O Manteca Dia" of Wall Excavation 'Dia. of Well Casing <br /> ❑ Domestic/Private <br /> g,( Gravel Pack jsi Tracy Type of Casing �✓ Specifications <br /> ❑ Public ❑ Other 0 Delta Depth of Grout Seal %n -}-O S_ 0t Type of Grout <br /> ❑ Irrigation 2_5_�;4pprox. Depth ❑ Eastern Surface Seal Installed;by 5 <br /> Repair Work Done ❑ Type-of Pump :E H.P. State Work Done <br />[j Well Destruction ❑ Well Diameter 2 1l Sealing rMaterial (top 501 <br /> f �Morihq W GII Depth 2 5 Filler Material (Below 50') <br /> F SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer" <br /> i available within 200 feet.) <br /> Installation will se esidence_ Commerlcial_ Other <br /> Number of{iving units: tuber of bedrooms <br /> Character of soil to a depth of 3 feet: I. Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Ca ' No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of, Disposal -_ik <br /> Distance to nearest: I`, Well ndation Property Line <br /> LEACHING LINE ❑ No. & Length of I length/size i <br /> FILTER BED ❑ Distanc nearest: ':j Well Foundation Line <br /> I <br /> SEEPAGE PITS ❑ Depth i Size Number <br /> SUMPS ❑ Distance to nearest: 9Well Foundation Property Line <br /> Di AL PONDS ❑ i f <br /> I hereby certify that I have prepared this applicationjand 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."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." If <br /> The applies us all r all n3quir spections. 'Complete drawing on reverse side. �j a U V-e j 0 C.l J <br /> / J <br /> Signed Title: /. Date.-" <br /> ... . I <br /> i R E ONLY: '. <br /> Application Accepted bDate ~1-- -Area i <br /> i <br /> Pit or Grout Inspe o y ? Date Final Inspection by Date <br /> J <br /> Additional Comments: <br /> ❑ Stk 466-8181 ❑ L i 369• 1 01KManteca WA04 ❑ Tracy <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. laojg <br /> Stk., CA 95201 -- <br /> R <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> I <br /> EH 13-24 <br /> + EH14-2g[REV.fies� 7 5 �� $•7_76 to <br />