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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON AVE-, STOCKTON, CA <br />I 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. <br />J aa <br />Job Addres r �G� Ci Lot Size - �/ <br />Owner's Name Address 0 0( J%r���-✓JZ{�L phone / Yom— -- <br />! ` + / <br />Contrac r� ddress r r License No✓&- Phon J <br />TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br />PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br />FOUNDATION _ AGRICULTURE WELL ._. OTHER WELL_ PITS/SUMPS <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS is <br />❑ Industrial ❑ Open Bottom ❑ Manteca ;�� Dia- of Weil Excavation`:- Dia. of Well Casing <br />'��. r 4 • v� \j• 1 <br />❑. Domestic/ Private _�❑ GrayeLP_ac _ D_Tracy__ x„_Type,of Casin¢�� �: Specifications <br />f'1 Public 1-1 Other C1 Delta Depth of Grout Seal Type of Grout _ <br />I I Irrigation ­Approx. Depth I I Eastern Surface Seal Installed by <br />Repair Work Done 0 Type of Pump / H. P. State Work Done <br />Well Destruction ❑ Well Diameter Sealing Material (top ,50') <br />Depth �/ Filler Material (Below 501 _ <br />TYPE OF SEPTIC WORK: h:EW INSTAL VI 0 NX, REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br />available within 207 feet.), <br />Installation will serve: Residence ; Commercial _ Other / <br />Number of living units: -/— Number, _ ©dro <br />Character of soil to a depth of 3 feet: <br />Water table depth <br />SEPTIC TANK .Type/mIg L � Capacity fa00 No. Compartments <br />PKG. TREATMENT PLT. ❑1/ , F Method of Di�posal <br />Distance t0'64rest: ' t Well 2 __. Foundation ._�� Property Line � -- <br />LEACHING LINE No. & Lenotth of lines _ Total length/size Ir <br />x u <br />FILTER BED ❑ Distance_to ,neatest, '-Well ! -SIV <br />— Foundation Property Line st <br />SEEPAGE PITS Depth --Site _ O Number _! <br />SUMPS t 1=1 Distance to nearest: Well /D�' Foundation Property Line_ 4 <br />DISPOSACPONDS.`" <br />[E <br />1 hereby certify that I have prepared this application and that—thework_wlll'be done in accordance with San Joaquin county ordinances, state laws, and <br />rules indl'egulatioris_of the San Joaquin_,Locaal Health Diktrict. A � �'- - - t ; <br />Home owner or licensed agent's signature certifies wis-following: "I certify that in the performance of the"Worl: 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 w <br />persons subject to orkman's cornponsa--,' <br />tion laws of California." - <br />The applicant st call for req d inspections. Complete drawing on,revers Pe. <br />Signed X Date <br />FOR DEPARTMENT USE ONLY <br />Application Accepted by `% ,._ Date lr� Area <br />Pi or Grout Inspection by ate -,.,,.17 Final Inspection by '�-" ly Date�J <br />Additional Commants: <br />❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ flanteca 823-7104 ❑ Tracy 835-6385 <br />Applicant - Return all copies to: Environmental Health Permit/Services 1631 E. Hazelton Ave., P.O. Bo'-: 2009, Si:•:., CA 95201 <br />EH 13-241REV. tit; 51 <br />EH 1428 <br />FEE <br />INFO <br />AMOUNfT�DUE <br />AMOUNT REMITTED CASH CK <br />RECEIVED BY <br />DATE PERIA11'NO. <br />C1 -Sl <br />rV <br />� <br />