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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ®(�� <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 f <br /> PERMIT EXPIRES TYEAR 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 �` City Sit-. Lot Size 97 6 X L.13. PM <br /> r j if I_ gII' <br /> Owner's Nam e �1 tAk1 fie c��If 1�F-� Address /70 r 5. Q►SK{ _ ky . Phone Y Z 7J <br /> Contractor j"r Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ."+PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHERWELL. / PITS/SUMPS ( , <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION CATIONS <br /> i <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca el Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing Specifications ` <br /> * Public ❑ Other E eltaDepth of Grout Seal Type of Grout--- <br /> I <br /> rout I I Irrigation --Approx.. I I 1 Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump - m-H:P. - - State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material itop 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION i I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) I v <br /> Installation will serve: Residence_ Commercial_ 01her` G J <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 /> a,. <br /> FILTER BED ❑ Distance to nearest:" Well 1 Foundation Property Line <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS L-1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 f <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 a <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." j <br /> The applicant m I for all quire inspections. Complete drawing on reverse side, <br /> l <br /> Signed X - Title: - Date: 2` 87 <br /> FOR IMPARTMENT USE ONLY <br /> Application Accepted by f.��►nn Date a Area <br /> Pit or Grout Inspection by p,{ Date �Ins� action by e- 0 Date ;0/l <br /> DI I <br /> Additional Comments: U V rt TI _6 6 <br /> a— t ' <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823 7104 racy 835- t <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk. A 5201 tL yt W,9 c_ <br /> F—FE—E—T AMOUNT DUE AMOUNT REMITTEDK H RECEIVED BY DATE PERMIT'NO. <br /> lNF <br /> + EH1 - 41REV.i/fa sl <br /> EH 144-226 v VVV o VQ <br />