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.u4 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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.. <br /> 1." S' �. � t� <br /> Job Address if City } 1'_ <br /> K Lot Size PM <br /> Owner's Name �•�-�7 1�. C0Uje r,� Address 47 O Cit) : S A LI . Phone 222 <br /> Contractor's:Name' &lir - I <br /> _ �� License No. Phone e <br /> TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPT K SEWER LINES DISPOSAL FLD. ROP. LINE <br /> FOUNDATION WELL ELL PITS/SUMPS <br /> INTENDED U5 TYPE OF WELL PROBLEM AREA CON ION 5 ' <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. o <br /> ❑ Domestic/Private. ❑ Gravel Pack ❑ T Type of Casing Specifications <br /> ❑ Public f ❑ Other Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation �qp epth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ of Pump H.P. State Work Done <br /> Well Destruction Well Diameter Sealing Material (top 50') 1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is <br /> 'f ilable within=200 feet.) <br /> Installation will serve: Residence Commercial a Other x <br /> z- <br /> Number of living units: Number;of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANKType/Mfg # Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑`' Method of Disposal <br /> r <br /> � distance to nearest: Well � - t Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearast:­W6 `" " "'F Foundation Property Line <br /> { I: <br /> SEEPAGE PITS j ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line t <br /> DISPOSAL PONDS. ❑ ". ` - <br /> ,. 1 <br /> I hereby certify that l 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: "l 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 becoMne subject to workman's compensation laws of California."Contractods hiring or subcontracting 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 II for all re u' V�pe!cns Comple drawing on'reevverse side. <br /> Signed .. Title:—CIL . ... �� Date: �� „ <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date � —U Area ©3 <br /> Pit or Grout Inspection b Date Final Inspection by D�8 <br /> `` <br /> Additional Comments: _ w l `` o <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 2W9, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"N0. <br /> + EH13-241REY.1418331 +e';'" 9 <br /> EH 1426 V <br />