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APPLICATION FOR PERMIT <br /> { SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE`TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1YEAR 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. <br /> Job Address 3y 2- S. E- _P® p S/ City Lot Size PM <br /> Owner's Name Address 877& 4 Y Ne, . ^'E,; Phone <br /> Contractor SPS Fc 7XJIAddressaORY-,ee icense No.�/ Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ -OTHER ER, C Pia <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Mapteca Dia.-of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 11 upblic ❑ O;her n Delta Depth of Grout Seal Type of Grout _ <br /> I'I irri�� —..Approx. Depth 1 I 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\�den <br /> INSTALLA N I1 REPAIR/ADDITIO I DESTRUCTION I I (No s tic system permitte public sewer is <br /> availabI within 200 feet.) <br /> Installation will ce_ Commer 'a!— Other <br /> Number of livinNumber of bedroom <br /> Character of sofeet: Water table epthPTIC TANKe/Mfg Capacity No. Compartm isPK . TREATMENMethod of Dispostance o nearest: Well Foundation Property Line q� <br /> LEACHING L E ❑ No: & Length lines Total lengt size \�\ <br /> FILTER BED ❑ Distance to neare Well Fou ation Prope Line <br /> SEEPAGE PITS I I Depth Size _ Number c <br /> SUMPS 1 Distance to nearest: II Foundation Property Line \/ <br /> DISPOSAL PONDS El <br /> I hereby certify that I'have prepaed 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." Contractor's hiring or sub-contacting 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 naust call for all requi inspections. Complete drawing on reverse side. <br /> Signed X Title: Z Date: 712,21120F <br /> _ <br /> FOR DEPARTMENT USE ONLY <br /> t <br /> Application Accepted by d9 Date °® Area <br /> Pit or Grout Inspection.by Date Final Inspection by Date <br /> Additional Comments: v ®-� <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 5-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. <br /> +,EHt3aalREtt.riMsr ir, <br /> 3S 0-06 <br /> �. <br /> EH 94.28 <br />