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s <br /> ti f <br /> { <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT y N0\AJ <br /> 1601 E. HAZE.T ON AVE. STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 11,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 /> Jab Address '�'S o 4) — <br /> EL—M 2 City 5 � Lot Size � PM <br /> r <br /> Owner's Name Address Phone <br /> Contractor k&)AL:ftASlAddress' .0.43icense 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 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL k PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca.' Dia. of.WeILExcavation .. Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack-1_ ❑ Tracy Type of Casing Specifications <br /> * Public ( ! Other H Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —_..Apprax.aDepth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done F un <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50 <br /> i <br /> Depth Filler Material (Below 50') _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION l 1 DESTRUCTION 1• septic system permitted if public sewer is <br /> available within 200 feet.! <br /> Installation will serve: Residence 1— " omrnercial_ -Other -� R <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. ❑ r Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines ' Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> 4 <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line ' <br /> DISPOSAL PONOS ❑ <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 Districts <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 /> rt'fies the following: "I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa-. <br /> ti _a f California <br /> The applicant call for I req 'ed in ct n Co lete drawing on verse side. <br /> r <br /> Signed•X -7itlai: � Date: <br /> DEPARTMENT USE ONLY �} <br /> Application Accepted by Date 3— ! "� Area <br /> ,Pit or Grout Inspection by T Date Final Inspection by_ C. Date <br /> Additional Comments: <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 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH �J 9 <br /> +.EH13-241REV.tiHsl 3 �o1z C!?� '� + / /f 3-7?P (2F <br /> EH 14-26 �/ <br />