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?` APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,.tSTOCKTON, CA <br /> T61eplione (209)'466-6781 <br /> i PERMIT EXPIRESA YEAR FROM DATE ISSUED <br /> .v,t 11%Vr � �• , t.. , r #,(Complete in Triplicates <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 sawage,or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. r <br /> Np' <br /> R 105 <br /> Job Address y� r City/. .,Lot Size PM �y <br /> Owner's Name d.—��[ _.p/1Ll _. ��J�� Address �! Phone 0 ' A <br /> Contractor Address License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER NES DI v SAL FLD. PROP. LINE <br /> FOUNDATION AGRICULT E WELT F OTHER WELL PITS/SUMPS € s' <br /> INTENDED USE TYPE OF WELL PROBLEM jAREA 'C0KSTjeeTION SPECIFICATIONS t <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca o . ell Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of ' Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth no— <br /> of Gro Seal ' Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ stern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction 71 Well Diameter 7 Sealing Material (top 50') �ln <br /> Depth Filter Material (Belorw 501 n� `��� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCT (No eptic system permitted if public sewer is <br /> av able within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other } <br /> i, Number of living units: Number of bedrooms y l <br /> i Character of soil to a depth of 3 feet: Water table-depth .. <br /> SEPTIC TANK ❑ Type/Mfg `_ - f Capacity No. Compartments <br /> I PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line ; <br /> LEACHING LINE O No. & Length of lines Total length/size r <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> { SEEPAGE PITS ❑ Depth Size' •'T '� 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 icounty ordinances, state laws; and <br /> rules and regulations of the San Joaquin Local Health District. 4. 1 r 1 <br /> Home owner or licensed agent's signature certifies the following: "I certifyFthat 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-contacting 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 /> i p • nt must call for all required inspections. Complete drawing on reverse side. <br /> Signed X 1I 1 Title: Date: �~ �' J <br /> _ DEPARTMENT USE ONLY <br /> Application Accepted by ? 21 <br /> Date r� Area L <br /> li Pit or Grout Inspection b Date , Final Inspection by Date <br /> Additional Comments: cz <br /> f ; <br /> f ❑ Stk 466-6781 5-6385 <br /> Applicant- Return all copies to: Environmental Health Perm_ it/5ervices,1601 E. Hazeiton Ave'.;-R.O. Box 2009, Stk., CA.95201 <br /> c <br /> FEE AMOUNT DUE; AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO @� '/� CASH <br /> + EH 13-24 4REv.t i H 55 �k+ �-. 3�•V0 ��(p 3-3—R-7 <br /> EH 14-28 <br />