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f. <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> k PERMIT EXPIRES 'I'YEAR FROM DATE ISSUED 1EA0S7-1.(6 `oT <br /> (Complete in Triplicate) 1>,-1al2 719 /97.;, <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 />' Job Address ^ '/ ��111­ot <br /> City Size_ e,—oe yS' • PM <br /> Owner's Name JrJ Address s Phone, 'AJ. <br /> s <br /> Contractor 'e gy- zyow,!A Address_ ] AA A P61— Aes " V <br /> License No. �Ya�Y7� Phone, <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L DESTRUCTION ❑ <br /> PUMP INSTALLATION 17) " SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial E1 Open Bottom ❑'Manteca" "" "Dia:_of:lNeEl"Eiccavatio`n Dia. of Well Casing <br /> ❑ Domestic/Private -0 Gravel Pack ❑ Tracy Type of Casing � Specifications <br /> FI i Public ❑ Other n Delta Depth of Grout Seal Type of Grout _ <br /> . . <br /> ! I IrrirJation Approx. Depth—1 I 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 50'1 <br /> Depth '— 'Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f 1, REPAIRIADDITI,O�N- DESTRUCTION I I (No septic system permitted it1public sewer is <br /> .. available within 200 feet.) C <br /> Installation wiil:serve: 'Residence Commercial_ Other d <br /> Number of livin -units- I �'- -• ----�� <br /> g �_ Number oflb�ed'rooms <br /> Character of soil to a depth of 3 feet: „0�+� _ Water table depth <br /> SEPTIC TANK I❑ 1 Type/Mfg' Capacity ' No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well : Foundation, "Property Line ° K <br /> LEACHING LINE No. & Length of lines:( '2Z Total] length/size,SV 'X L <br /> FILTER BED ❑ Distance to nearest: Well `400-r- Foundation O: Property Line—44a <br /> SEEPAGE PITS Depth .- '�r Size 3 3 rr _ Number <br /> SUMPS ❑ Distance to nearest: Well 1 Property Line <br /> �_ Foundation�.0 Jam_ <br /> DISPOSAL PONDS ❑ 4 <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 E <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 call for all required inspections. C mplet�Fe�dbrawing on reverse side. t <br /> Signed X Tit[e� `! <br /> .- Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date <br /> Area <br /> Pit or Grout Inspection by Date T T Final%Irtspection by Date o! +$ <br /> Additional Comments: l <br /> L1 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 ' <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I <br /> FEE AMOUNT DUE AMOUNT REMITTED' <br /> INFO .q� CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13.24(REV.118 5} - vV<� `j <br /> EH 14-26 90 - .. �� �A �. <br /> V � <br />