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APPLICATION FOR PERMIT `` E <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CAT © 9 1992 <br /> Telephone (209) 466-6781 ENVIRONMENTAL HEALTH <br /> PERMIT EXPIRES 'I YEAR FROM DATE ISSUED PERM IT/0"VI00 <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 _-/Cf� < V ^4"'" � City Lot Size +'y/7 " PM <br /> Owner's Name ��LC *"�G'� " +✓ Address " Phone -3 7- / c?/- <br /> C o n I r a c I o r <br /> Contractor-Aa4tA r l Address ! icense No. Phone?W4 A2- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERK <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 /> FI Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout <br /> i I Irrigation .Approx. Dept l I Eastern Surface Seal Installed by _ r, <br /> Repair Work Done L7 Type of Pump H.P. 20 State Work Qone <br /> Well Destruction ❑ Well Diameter Sealing Material Stop 50') z' " <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 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 I 1 Depth Size Number <br /> SUMPS ❑ Distance to nearest: Weil 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 Aust call for allreuir inspections. Complete drawing on reverse side. <br /> Signed X 67/ Title: Date: <br /> F R=ThIENT E ONLY <br /> 0 7 <br /> Application Accepted byLLDate 9� 2Area � <br /> Pit or Grout Inspection by Date Final Inspection by +C [ ata <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 /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK R IVED BY DAT PERMIT IVO. <br /> + EH13.24IREV.i i n s� / �y O-U <br /> EH N'29 n �:/ �� <br />