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APPLICATION FOR PERMIT <br />` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA A10 P/T <br /> Telepho'he (209) 466-6781 r l <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 /> Job Address -7.Z � <br /> 7�--:#J City fm r1 Lot Size ?O x t7 l PM <br /> Owner's Name -EZa Le,076_e raw w for Address __S� <br /> 1 Phone <br /> Contractor alvw E V47 i Address /[VJh.eP f' <br /> License No. L-'� 2 76 Phone -3 7/ <br /> TYPE OF WELL/PUMP: NEW WELL E3 WELL REPLACEMENT [I DESTRUCTION ❑ <br /> -PUMP INSTALLATIO ❑ SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST:.SEPTIC TANKSEWER LINES <br /> a ­: DISPOSAL FLD. PROP. LINE <br /> FOUNDATION GRICULTURE IrV OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM EA ONSTRUCTION-SPECIFICATIONS <br /> L1 Industrial ❑ Open Bottom ❑ Mantec Dia. of Well Excavation <br /> ❑ Domestic/Private ❑ Gravel Pack Oie• of Well Casing <br /> ❑ T Y Type of Casing <br /> M Public Cl Other11 1 Specifications 4 <br /> Delta D th of Grout Seal <br /> i I Irrigation I Approx. p Type of Grout <br /> y .l I.Eastern Surfa Seal Installed by <br /> Repair Work Done ❑ Type of Pu <br /> H p _ <br /> State Work Done <br /> Well Destruction ❑ _ <br /> Well D meter Sealing Material (top 50') <br /> Depth .Filler Material_(Below:50,)_� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'I R- AIRLADDITION I I D TR CTION { <br /> } (No se tic system permitted if public sewer is <br /> r <br /> Installation will server Residence_X_ Commercial <br /> le within 200 feet.)Gommercial_• fOther' <br /> Number of living units: r Number of bedrooms_07- . r <br /> Character of soil to a depth of 3 feet: s V! <br /> SEPTIC TANKI Water table depth <br /> 1,1� Type/Mfg Capacity o. Compartments <br /> PKG. TREATMENT PLT. ❑ - - -_._ <br /> Method of Disposal <br /> Distance to nearest: well Foundation <br /> � Propt3riy.Line <br /> LEACHING LINE ❑ No. &.,Lengih.of lines <br /> Total length/size <br /> FILTER BED 'EJ Distance to nearest: Well <br /> C Foundation Property Line <br /> SEEPAGE PITS I I Depth Size <br /> SUMPSI Number <br /> LI Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <br /> 1 I <br /> I hereby certify that I 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 g 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." <br /> The applicant must call for all required in <br /> mplete drawing on reverse side.— <br /> g '� Title: <br /> Sined _ Date: <br /> 1 R DEPARTMENT USE ONLY q <br /> Application Accepted by Date �3 l� y <br /> -.} Area <br /> Pit or Grout Inspection by 1 Date Final Inspection by <br /> Date 2 G <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> t <br /> FEE ! <br /> INFO AMOUNT DUE AMOUNT REMITTED CASK RECEIVED BY jDATERMjIT'N .+.EH13-24(REV.Ii35) �� 'y "'�G `� 'EH 1428 7 V , ( /'� .. <br />