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�. APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> 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 /> f 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 / f0 C11Gyt Lot Size PM <br /> Owner's Name / �'.ry Address -"£-��- ' Phone 67Y, <br /> , <br /> a �t Q' <br /> Contractor• Address License l s PhoneY6 � f' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 <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 <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 © Tracy Type of Casing Specifications <br /> 1` Public yy n Other f] Delta Depth of Grout Seal Type of Grout _ <br /> I 1 Irrigation !L =-Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done '0 4 Type of Pump H,P. State Work Dbne_ <br /> Well Destruction s❑. Wel! Diameter . - - Sealing Material.1 top 50'1- <br /> Depth Filler Material (Be-low 50'1 <br /> -` TYPE OF SEPTIC WORK: NEW INSTAL 11 REPAIR JADDITION - DESTRUCTION l I (No septic system permitted it public sewer is <br /> 1 available within 200 feet.) <br /> Installation mill serve: Residence L Commercial— Other VV <br /> M1 Number of living units:- Number-of bedrooms <br /> Character of soil to a depth of 3 feet: t Water table depth' <br /> t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> P.KG.TREATMENT PLT. ❑ Method of Disposal <br /> '-Distance to nearest: Well Foundation Property Line <br /> 1 <br /> LEACHING LINE No. 6 Length of lines �'S• -- Total-length/size Z r <br /> _�. FILTER BED ; Distance to nearest: Well _ CIO f Foundation �� J' Property Linef I <br /> SEEPAGE PITS Il Depth Size I Number <br /> SUMPS, Distance to nearest: Well Foundation T f! fly Property Line <br /> DISPOSAL�PONbS ❑ <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-Df�trict. <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'si'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 obCalifornia." <br /> The applicant u t :all fpr all iequied ins ions. Gomple a drawing on reverses si <br /> Signed Date: <br /> T USE ONLY <br /> Application Accepted b AoN Date � Area 13p <br /> Pit or Grout Inspection by 1 Date / Final Inspection by Date <br /> 61 <br /> Additional Comments: T (/ 0 U�,r /?�dd�s lGh1 s <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., C 95201 <br /> S f. <br /> FEE <br /> y t <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK 4 RECEIVED BY DATE PERRMIT'NO. <br /> +.EH13-241REV.r/ns1 <br /> EH 14-28 �+ 1 <br />