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4 <br /> APPLICATION FOR PERMIT I <br /> ` + SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.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 /> 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, Vq e: , W-- 7� �^ <br /> Job Address <br /> gL��. NS'7'y _ City � � Lot Size-> L PM <br /> Ij <br /> Owner's Name ,1 Oddress - Phone <br /> Conlractor, V , Address t License Nv.��Q 7 _Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIRC9. 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 CONSTROCTION SPECIFICATIONS } <br /> ❑ Industrial E1 Open Bottom Ll Manteca Dia-of Well Excavation Dia. of Well Casing <br /> 0 DomesticlPrivate ❑_ Gravel Pack LlTracy Type of Casing Specifications <br /> FI Public ❑ Other '`, ❑ Delta Depth of Giout Seal Type of Grout—__ <br /> r!igafion <br /> rout - <br /> rngauon Approx. Depth �l I Eastern Surface Seal Installed by - <br /> Repair Woik Done Ll Type of Pump _ H•P- U.. State Work Done_ <br /> �V77ell.-Destru6tion ❑ Well Diameter Sealing Material Itop 50'1 <br /> Depth Filler Material (Below 501 <br /> rtvTYPE'OF SEPTIC WORK: NEW INSTALLATION ('I REPAIR7ADDITION l I DESTRUCTION,1-1 Mo septic system'perrnitted if"public sewer is Q� <br /> available -J <br /> within 200 feet <br /> i k!r�,fl k }fnsta`iletl�tn vv'ill serve: Residence_ Commercial_ Other <br /> a} a ri `!; tumt3er jiving units: Number of bedrooms f <br /> Character of sail to a depth of 3 feet'-.'' Water table depth <br /> r (� t <br /> SEPTIC TANK ❑ Type/Mig 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 Y F ' Property Line <br /> SEEPAGE PITS I 1 Depth Size _ Number <br /> SU <br /> APS '" D Distance to nearest: Well 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 I' <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 fbr which this permit is issued,l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant ust call far ail required inspections. Complete drawing on reverse side... , <br /> Signe Title: L Date: <br /> III ,y OR DEPARTMENT USE ONLY4L <br /> Date_ -3 51 Area <br /> Application Accepted by" <br /> Pit or Grout inspection by Y 'p Date Final inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 C Tracy 835-6385 <br /> Applicant - Return all copies to: Environinental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85.201 <br /> FEE MOUNT•DUE AMOUNT REMITTED CK r• RECEIVED BY DATE PERMIT'NO. <br /> INFO _ +CSC f��\ 2C/A{�S(�HJ/j/ f�//7 /��`} <br /> ..EH 13-24 IRE lin s1 � si{� ,JJ MVV3/ 0 [// <br /> IF EH 14.26 _ <br />