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' APPLICATION FOR PERMIT F_ S r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ! <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA Z) t"?F_U5/ o W 0 F-Y-5 <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 at� <br /> permit to construct and/or install the work he ' 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 Lot Size PM <br /> Owner's Name a''�� el Address !� 1 Q•^M *7 y7LO''y / <br /> �_- �d� PF1one <br /> Contractor ®W n e✓-" Address <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE A <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS \\ <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 'i Depth of Grout Seal Type of Grout <br /> ❑ Irrigation —Approx. Depth Q*Eastern / Surface'Seal Installed by ' <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION 3KNo septic system permitted if public sewer is <br /> available within 200 feet.] 5 <br /> Installation will serve: Residence X_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:. Water table depth <br /> r' <br /> SEPTIC TANK F1 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ / Method of Dis�osal i�� 4a <br /> Distance to nearest: Well Foundation �� r Property Line�_ <br /> LEACHING LINE ❑ No. & Length of lines nt Total length/size <br /> FILTER BED ❑ Distance'm neatest: '- Well 'Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ 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 <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 /> The applicantAust call for all required inspections. Complete drawing on reverse side. <br /> Signed Title: e/ "Z 3-- <br /> Date: <br /> FOR EPARTMENT USE ONLY <br /> i <br /> Application Accepted by Data `c�3 Area <br /> Pit or Grout Inspection by Date Final Inspection by Det <br /> Additional Comments: <br /> ❑ Stk 466-6781 Q Lodi 369-3&1 ,rilanteca 823-YW ❑ 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 gMOUNT DUE AMOUNT REMITTED CK RECEIVED BY. DATE PERMIT'NO. <br /> INFO CASH <br /> + EH13-241REV,5iasY � S -CSO ~. <br /> EH 14-28 /8-7 <br />