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rl APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> k Telephone (209) 466-5781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 4 (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 /> I Local Health District. <br /> ' k <br /> Job Address �✓ i�Q yL��Ga y 5ro�l�'To Lat Size s'V_f-lkweo <br /> % Cit PM <br />} Owner's Name P <br /> 7Y!c If 'Irfrl0 <br /> Address 1.11416 Phone <br /> 4 Contractor ;+44,T M e SVA/ Address P70X QGt9ev A¢ <br /> /5fvp'. License Ko.'Y5 elrl Phone•rx3-"��2"� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIDN ❑ <br /> PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 4SEWER 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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Trac <br /> Tracy T ype of Casing Specifications <br /> I <br /> i Public t7 Other C f Delta Depth of Grout Seal Type of Grout 9) <br /> r Irrigation --Approx. IDepth- I I Eastern Surface Seal Installed by— <br /> Repair Work Done L1 Type of Pump H,P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material,(top 501 <br /> Depth i t Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION Wr REPAIR/ADDITION ( J DESTRUCTION i I (No septic system permitted if public sewer is <br /> available within 200 feet.► <br /> Installation will serve: Residence f Commercial_AI Other O�ri� HG�W <br /> ' Number of living units: 0 Number of bedrooms_40 oC_ <br /> Character of soil to a depth of 3 feet: Water <br /> table depth <br /> SEPTIC TANK PS Type/Mfg P�a� Capacity !BOO No. Compartments A <br /> PKG. TREATMENT PLT. ❑ Method of Disposal ` <br /> Distance tt),nearest: Well Foundation Property Line f <br /> c <br /> rs LEACHING LINE a No. & Length of lines 2 �+a ' Total length/size LS ' <br /> FILTER BED ❑ Distance to nearest: Well 1 V a Foundation <br /> ! I _3-4?�� Property Line <br /> SEEPAGE PITS 1 j7d Depth # 5- Size .1�6 • �7%�• <br /> Number # <br /> SUMPS C7 Distance �totnea' Foundation­ Well �s- Property Line oundation /�O <br /> DISPOSAL PONDS Li1 , <br /> 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 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." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X <br /> f Title: Date: <br /> I FOR DEPARTMENT USE ONLY ' <br /> Application Accepted by <br /> Date 4- Area �21 <br /> Pit or Grout inspection by Date— Final Inspection by f/ <br /> Data <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ 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 96201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> - INFO CASH RECEIVED BY PATE pERMIT�NO. <br /> 14 <br /> +.EH -24lREV.t/H51 W 9l-07$�vsv <br /> EH 14-ZB <br />