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APPLICATION FOR PERMIT CU4$ <br /> - SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE:, STOCKTON, CA AUG ( jsjdo <br /> Telephone (209) 466-6781 , <br /> PERMIT EXPIRE$ 1 YEAR FROM DATE ISSUED ENV]Ru villi i l AL HEALTH <br /> (Complete in Triplicate) 1. _ FERMIV.SERVICE.8 <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. rwftf' <br /> ,fob Address <br /> CityLot Size 3 PM <br /> Owner's Name -Y�/V�/�/Q . k/� ,Address Phone <br /> Contractor Address icense No. phone <br /> TYPE OF WELL/PUMP: NEIN WELL ❑ VI/�FLL REPL.AGEMEN7'Cf] DESTRUCTION ❑ <br /> PUMP INSTALLATION ,01L S ,e i STEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL, _ OTHER WELL PITS/SUMPS <br /> - <br /> INTENDED USE'S TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Wel! Casing <br /> JV Domestic/Private ❑ Gravel Pack ❑ Trac T s <br /> Y Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout)Seal Type of Grout t <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> i <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done p pV <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50') i SP- <br /> Depth Filler Material (Below 501 V F <br /> TYPE OF SEPTIC WORK: ,NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is <br /> j available within 200 feet.) <br /> Installation will serve: Residence, Commercial— Other ( � <br /> I <br /> Number of living units: Number of bedrooms r <br /> Character of soil to a depth of 3 feet. W er tableI depth ! <br /> SEPTIC TANK ❑ —tapacitv __. N+%Compartments j <br /> PKG. TREATMENT PLT. ❑ rMdhod of Disposal <br /> Distance to nearest: Well 'Foundation 7 1 Properry.`Lfne <br /> s_.a.�;� L ,, fi <br /> LEACHING LINE ❑ No. & Length of lines i )Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundationf <br /> Property Line <br /> SEEPAGE PITS ❑ Depth Size Number !, <br /> SUMPS ❑ Distance to nearest: WellFoundation 1 Property Line ) <br /> DISPOSAL PONDS ❑ <br /> 1-hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, anot <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 m st c �f all regui•e ipections. Complete drawing.on rave side. <br /> Signed Title: i Date: <br /> If <br /> OR DEPARTMENT USE ONLY �� <br /> Application Accepted by Date Area 4 <br /> 0 ?moi <br /> Pit or Grout Inspection by Dater Final Inspection by ` Date <br /> Additional Comments: f <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> a 9 <br /> FEE AMOUNTDUE AMOUNT REMITTED CK RECEIVED 9Y DATE PERMIT N0. <br /> INFO CASH <br /> + EMI <br /> 3-24SREY.t/e51 1 <br /> �J � � $b , <br /> EH 1428 / <br />