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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTONPA~, CA R,EC ME'NT <br /> Telephone (209) 466-6781 <br /> I. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AUG 12 <br /> k �J (Complete in Triplicate) -' j9(�,� <br /> i - -ENVIRO <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install tl�§ Q��if h{i]igf�}�s r ed. This application is <br /> made in compliall with San Joaquin County Ordinance No.549 for sewage or No.1862 for well/pump and the"RNl@��/ Ig tNhe San Joaquin . <br /> Local Health District.. CE <br /> j <br />' Job Address CityLot Size Ail ii PM <br /> L -perti. <br /> Owner's.Name "' '" Address, N, 6WAJV hone <br /> Contractors Address License 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 PITS/SUMPS _ <br /> - . <br /> INTENDED Us1SE _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial• jf ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> j ❑ Domestic/Priv,, to ElGravel Pack El'Tracy Type of Casing Specifications <br /> 1 M Public n Other 1-1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation I� ---Approx. Depth I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump. H.P. State Work Done_ <br /> Well Destructionli ❑ Well Diameter Sealing Material (top 501 <br /> i <br /> I� Depth -- —•~ W Filler Material•(Below 50')-- <br /> TYPE <br /> 0')-TYPE OF SEPTIC WORK: NEW INSTALLATION I.l REPAIR/ADDITION LI DESTRUCTION l l (No septic system permitted if public sewer is <br /> I� available within 200 feet.) <br /> Installation wi e: Residence_ Commercial_ Other <br /> �k ., <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth o et: Wwrrable depth r. <br /> SEPTIC TANK ❑ Type/Mfg Capacit No. Compartments <br /> PKG. TREATMENT PLT.❑ y. Method of Disposal <br /> Distance to nearest: Foundation Property Line <br /> R <br /> l <br /> LEACHING.LINE o. & Length of lines Total length/size <br /> f FILTER BED 0 Distance to nearest: Well Foundation - �Popertye <br /> EEP_A,GE PITS - .I 1=_-Depth Size- -,—.:-.,, ._ Number .: <br /> SUMPS L1 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 /> I rules and regulations of the San Joaquin Local.Health District. <br /> I 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 /> 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 compens; <br /> kk tion laws of Califomiil <br /> ' <br /> T a licarr o f call for all r uir ins p g r verse.side. <br /> I pp � inspections. Complete drawl on re <br /> Signed X ''�-t. nFF <br /> 7 <br /> Date: ' <br /> F, DEPARTMENT USE ONLY <br /> Application Accepted by Date 7^ ' Area, <br /> Pit or Grout Inspection by Date Final Inspection by r Date . <br /> Additional Comments: <br /> Still 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Trac 835-6385 - <br /> pplicant eturn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> I 6 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> EH 13 24 _ Re 4Q�EH 14-28(REV.t/H5) Vs . '✓`� ? QO-�/?3 <br /> i <br />