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rF- <br /> ��' APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZED ON AVE., STOCKTON, CA <br /> Telephone I209i 466-6781 <br /> s 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 /> 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 1�a 7 Clko,'yr c� City `�'�C'7/� Lot Size <br /> " PM <br /> Owner's Name 00 W 1 !r �Cddress / T ��l`rO��CL C -3--53q <br /> _ _ Phone 2 / <br /> Contractor Address y License No. Phone <br /> YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYST M REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS <br /> I <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 /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx..Depth ❑ Eastern Surface Seal Installed by n <br /> Repair Work Done ❑ Type of Pump H,P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material atop 501 <br /> Depth Filler Material (Below 501 v <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION W(No septic system permitted if public sewer is <br /> kr available within 200 feet.) <br /> Installation will serve: Residence XC Commercial— Other <br /> Number of living units: _._._� Number of bedKooms <br /> a7 <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 O <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 ❑.3; Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O ' <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 /> I c` The applicant rpVst c I for all r q Fred inspections. Complete drawing on reverse side. <br /> x Signed X _- ill Title:5 Or 6(��C-#. Date: <br /> } !! \\ FOR DEPARTMENT USE ONLY <br /> ' Application Accepted by Date `� — Area v <br /> s <br /> Pit or Grout Inspection b Date I Inspection b Date <br /> I Additional Comments: <br /> o �e , <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 2000, Stk., CA 95201 <br /> FEE r <br /> INFO AMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24(REV.t R 5) <br /> EH 1428 <br />