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V� O <br /> APPLICATION FOR PERMIT <br /> 4�AG ,J�Ci SAN JOQUIN LOCAL HEALTH DISTRICT <br /> HAZELTON ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> ���`����\ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> \�0��\ (Complete in Triplicate) <br /> Applicwo is eby 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 Otdinance.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 / r-* ! L G Od City <br /> *4 C-41 -Lot SizeIt-g �346 <br /> P <br /> 9 21 <br /> Owner's Name SIN 7�M -0, 1 r* T Q t /�F f< 1� t <br /> / Address Q Phone 3 .773Y <br /> Contractor's Nan'Rr-=� r� ic se No. /V Phone?V:t i <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ f DESTRUCTION ❑ <br /> PUMP INSTALLATI■O SYSTEM REPAIR El OTHER El <br /> _._DISTANCE TO NEAREST:-SEPTIC TANK SEWER LINES _! C�N DISPOSAL FLO. PROP. LINE „ ! <br /> FOUNDATION AGRICULTURE+WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �N <br /> ❑ Industrial pen Bottom ❑ Manteca Dia. of Well Excavation - Dia. of Well Casing {� <br /> 9;,11omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 51' 2k-J Specifications �J ' <br /> 11Public ❑ Other LJ Delta De th of Groin. Seal <br /> p �th, ._- Type of Grout <br /> Rl'Gngation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump 'L/ g::� H.P. L-, State Work Done.' <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 14 ( <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑- (No'septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <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. ❑ Method of Disposal Pt <br /> �f Distance to nearest: Well Foundation Property Line <br /> f. <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation' 'p f ' Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑"'Disiance 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. I ' <br /> Home owner or licensed agent's signature certifies the following: "I certify that 1n 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 9 <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 applicant must <br /> ^call <br /> lffor all required inspections. omplete drawing on reverse side. <br /> Signed X� �.�a�+ Title: _ Date: f <br /> r rF I <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date W a f aaq <br /> -7 Area 0 <br /> Pit or Grout Inspection by Date 9 J 25`� Final Inspection by- Date �I <br /> Additional Comments: j <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 - ❑ Manteca 823-7104 ❑ Tracy 835-63% 1 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE I <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT` j <br /> + EH 13-24(REV.10183) <br /> EH 1428 [[ 1 <br />