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I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone.1209) 466-6781 <br /> " /�y��� r� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> [V �I/ (Complete in Triplicate) r <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 /> r <br /> ^' City a Lot Size • ' t PM <br /> Job Address <br /> Owner's Name /z�}°��KfA+t�{J Address �749CI Roo 06 ` ' Phone <br /> Contract <br /> Address `-' License No.I Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL RE CEMENT ❑ DESTRUCTION ❑ <br /> - PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 11DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL`" ' PITS/SUMPS <br /> I } INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> L <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> El Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout r 1 <br /> ` ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by W <br /> "°Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501) <br /> l Depth Filler Material (Below 501 <br /> i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO ;REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> r Installation will serve: Residence Commercial_ Other <br /> 'Number_of living units: Number of bed ooi s t <br /> >,Character of soil to a depth of 3 feet: Water table depth <br /> x_ <br /> SEPTIC TANK FType/Mfg t Capacity-\2 j250 No. Compartments <br /> ° .PK& TREATMENT PLT'1 {�_ a } ' " Method of Disposal <br /> - # Distance to nearest: F WeI� Foundation \d Property Line ! <br /> BLEACHING LINE No. & Length of lines Total length/size d <br /> FILTER BED ❑ Distance to nearest: Well Foundation�� Property Line <br /> } SEEPAGE PITS 1 - Depth ' Size l "may , N tuber <br /> { ,.SUMPS .1 ❑ Distance to nearest: Well�f Foundation�i2 " Property Line <br /> IDISPOSAL 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 C) <br /> rules and regulations of the San Joaquin Local Health.District!, - . `-. <br /> " ^ 4 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 Cal'Ifornia." <br /> k The applicant rliu,$t call for all uired in ctions. Complete draiMng on reverse <br /> side. <br /> SignedTitle• L.C/ Date: <br /> l q F <br /> j ., ,xIr <br /> •- FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ~ � ea <br /> Pit r Grout Inspect by Date Final Inspection by Date } <br /> t 4 1 •s� :` ,L 3 <br /> I { Additional Comments: <br /> -;i4tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-5385 <br /> f -'Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O..Box 2009, Stk., CA 95201FEE <br /> w 3 <br /> r <br /> INFO AMOUNT DUE 'AMOUNT REMITTED a CASH `' "RECEIVED BY DATE f ERMIT''NO. <br /> + EH 13-241REV.1/851 H/ O AD fti K O`C +•.��~ � <br /> �.- EH 14-28 „O •���" a r`I 1 E <br />