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111 ✓ `�`# z ✓ '�F . <br /> I. 1 <br /> � -� APPLICATION FOR PERMIT <br /> SAN JOAO.UIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA _fin ' <br /> Telephone (209) 466-6781 N,0 *,A <br /> PERMIT EXPIRES.1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> I� <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. rI / 7 <br /> Job Address r 0� C 11�VlAIAcity Size A2QS-3 ' PM <br /> Owner's Name C&fL ::f/VZ/ &1Address �o / Y Chi��Ni� Phone <br /> Contractor_ S/5 I—/" Address -SH License No. Phone <br /> TYPE OF WELL/PUMP: ., NEW WELL'O WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA a CONSTRU&ION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done O <br /> Well Destruction ❑ Well Diameter Sealing.Material Itop 501 <br /> Depth er Materia low?50'} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: IWater table depth <br /> SEPTIC TANK X Type)Mfg 1 Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ / Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance_to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 II for all required inspec ions. Complete drawing on reverse side. /} <br /> Signed o Title:'.-, (fN�`t _ Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by w Date me ©� <br /> Pit or Grout I-Pn <br /> Gtio Date Final Inspection by Date <br /> Additional Comments: k <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED 13Y DATE PERMIT'NO. <br /> INFO <br /> +EH1 -241flEV.t/a51 �` Q OLI —\ <br /> EH 1428 I <br />