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"* APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> iComplete 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 /> I-30994 AU " �y Got <br /> Job Address <br /> ,��1�/�� City ����BI�/G�Lat Size PM <br /> Owner's Name /1A1-11- Address � '¢� feXa5e Phone <br /> Contractor $ Address_o!(rr7 &2 ZZ 2 License No. Phone — <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION R 9ZPA4V.FW444YSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL ,6�HER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIOM4PECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom 1 ❑ Manteca Dia. of Well Excavatirin W Dia. of Well Casing *� <br /> ,70oinestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ("' i Aly Specifications <br /> ❑ Public ❑ Other _ ❑ Delta Depth of Grout Seal . ? Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed;tiy _ <br /> Repair Work Done LlType of rump H.P. Stale'Work Done r <br /> Well Destruction ❑ Well Diameter Sealing Material [top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION C7 (No septic system permitted if public sewer is <br /> — ______L available within 200 feet.} <br /> Installation will serve: Residence_ Commercial_``Other M--, It n <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 I Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal ! <br /> Distance to nearest: V lelf Foundation Property Line <br /> LEACHING LINE ❑ No. &'Length of lines Total length/size <br /> FILTER 8ED ❑ Distance to nearest: . ell Foundation Property Line <br /> -A <br /> SEEPAGE PITS ❑ Depth "'" `Sgize Number <br /> SUMPS ❑ 136tande to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ y I <br /> I hereby certify that I have prepared this application and)hat 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 /> rifia <br /> Home owner or licensed agent's signature ces'the fonowing: "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 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 appiicant I r all r r inspections. Compiete drawing on rave side. ] <br /> Signed Title: Date: <br /> F DEPART ENT USE ONLY <br /> �. "��—SJ / _ <br /> Application Accepted by Date co Area <br /> Pit or Grout Inspection byDate Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6181 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> + EH 13-24(REV 5/85} S, 0-6 ;;23-� <br /> EH 1428 <br /> . I S <br />