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APPLICATION FOR PERMIT <br /> Q SAN JOAQUIN:LOCAL,HEALTH DISTRICT <br /> ` 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r (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. TNs 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. I <br /> Job Address �� City Lot Size L" Q ©9 PM <br /> Owner's Name Address •,- <br /> i �^'/ 1_AA1d5 Phone <br /> II Contractor's Name FZy© r AVLicense No. 3 27G Phone 46P 3'7-7 <br /> i TYPE OF WELL/fUMP: NEW WELL ❑ WELL'REPLACEMENT ❑ DE5TRUCTION'C7 <br /> _ ---- --� PUMP INSTALLATION ❑ 'S,YSTEM REPAIR Ll OTHER ❑ <br /> DISTANCE TO fV $T- SEPTIC TANK SEWER LINES, P DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTUAE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA ;CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 17 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑=Domestic/Private ❑ Gravel Pack{ ❑ Tracy Type of Casing Specifications l <br /> ❑ Public ❑ Other 1 ❑ Delta Depth of Grout Seal= <br /> p �` Type of Grout I <br /> ❑ Irrigation 41. _. _Approx. Depth ❑ Eastern :!Surface' Seal Installed by <br /> Repair Work Done d Type of Pump �Z H.P. State Work Done 66� <br /> Well Destruction ❑ -Well Diameter Sealing Material {top 50'1 ' :, t N <br /> I i t <br /> Depth Filler Material (Below 50'} , <br /> t TYPE OF SEPTIC WORK: NEW INSTA ELATION crT <br /> REPAIR/ADDITION 0 DESTRUCTION.❑ (No septic system permitted if public sewer is <br /> available within 200 feet.( <br /> Installation will serve: Residence 1Commercial_ Other '`.' <br /> Number of living units: I Number of bedrooms <br /> I Character of � <br /> soil to a depth of 3 feet:( l - y <br /> f , e_ Water table'depth <br /> SEPTIC TANK i'Type/Mfj Capacity bad <No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1 - i <br /> y Method of Disposal <br /> Distance to nearest: Well Found; n /d`h Property Line__�_ ~• <br /> LEACHING LINE �No. & Length of lines'°a ,� .. Nota! length/size •/7C7 f�( Z <br /> FILTER BED ❑ Distance to nearest: "I Well--/`�d• Foundation� Property Line <br /> SEEPAGE PITS Depth �� Size 3 J� Number <br /> SUMPS ❑ Distance to nearest: Well 241!0 Foundation Property Line <br /> DISPOSAL PONDS El <br /> f <br /> s 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 1 <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, 1 shall not <br /> employ any person'in sucf✓-manner as to become subject to workman's compensation laws of California."Contractors hiring or sub contracting signature <br /> _I pertifies the followr'rng:rl certify that in the performance of the work for which this permit is issued, I shall employ pers6ns subject to workman's compensa- <br /> tloh Aaws of California." t , <br /> The appGca"nt must call for all required inspections. Complete drawing on reverse side. <br /> Signed .« ` -'Title: Date:- — 2 1? <br /> T <br /> ' FOR DEPARTMENT,:USE ONLY I <br /> Application Accepted by JJ � Data 6?,Z_/ <br /> Area <br /> Pit or Grout Inspection by Date f� Final Inspection by Date d <br /> Additional Comments: <br /> '- --Q-Stk--466-6781—❑-Lodi 369-3621.--..0 Manteca=823-7104.- w.-0 Tracy-..83x6385 �...� <br /> Applicant- Return all copies to: Environmental Health Permit/Services 16D1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE ICK 71 <br /> NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> + EH 14-24(REV.10/63( <br /> EH 1426 �. � <br />