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411 <br /> I APPLICATION FOR PERMIT r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON 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.S49 for sewage or No. 1861 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address C l r, <br /> � t�s City Lot Size l ;o X� <br /> Owner's Name 1E Address Phone <br /> Contractor 1Hdress ,S-b =C_L. y 30g t <br /> Lic a nse�No.• �Phone <br /> TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> INSTALLATION L1 .� SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES- _- DISPOSAL FLD. PROP, LINE <br /> FOUNDATIONAGRIC ELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA' IFI <br /> CONSTRUCTI CATIONS <br /> ❑ Industrial El Open,8ottom "❑ Manteca Dia. of Well Excavation j <br /> v- �i Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑'Tracy f-=-Type of Casing ecifications <br /> ❑ Public k Q,Other O Delta 1, Depth of"Grout Seal T ut <br /> .E. type <br /> ❑ Irrigation �pprox. Depth El Eastern Surface Seal'installed by <br /> Repair Work Done ❑ Type of Pump H.P. 1�, 4 ,State Work Done <br /> Well Destruction 0 Well Diameter Sealing-Material (top 50')F` <br /> Depth + Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUC O septic system permitted if public sewer is <br /> . � `aseptic <br /> within 200 feet.) <br /> Installation will serve: Residence J Commercial V Other R 1.1 <br /> Number of living units:"�a "Number of bedrooms <br /> Character-of.soil to a"depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ T <br /> ype/Mfg Capacity��Y-�. No. Compartments <br /> PKG. TREATMENT PLT. ❑ j Method of Disposal <br /> t <br /> ' i t Distance to nearest: [-Well- — - -Foundation Property Line <br /> LEACHING LINE` ❑ No. & Lenith of lines <br /> g Total length/size <br /> FILTER BED 0 Distance t' nearest: Well ' Foundation Properly Line <br /> + - <br /> SEEPAGE PITS ❑ Depth '1 Size "r'F 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 Sari 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 /> e loy any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> • <br /> certi s the follow n "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 la ofCat'ort <br /> nia. ' mmi 1 x <br /> appli m call f all re ired i pectin lets drawing on reversesid l <br /> Sign ad Title: <br /> Date: 3 U CJ <br /> FORA4PARTIVIENT SE ONLY <br /> Application Accepted by Date T 1- Area <br /> Pit or Grout Inspection bye Date Final Inspection by Date'? l ' <br /> i <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca -71 ❑ Tracy 835-6385 tl <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 lvvJ <br /> FEE AMOUNT DUEAMOUNTIREMITTED'' .: <br /> INFO 'RECEIVED BY GATE PERMIT`NO. <br /> s + EH 13-241REV.i/g5) ` <br /> EH 14-28 Cha �/9/ 7� <br />