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1 <br /> APPLICATON FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> a 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> jI � . f <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 /> -x <br /> City Lot Size y lsu PM <br /> Job Address <br /> Owner's N/ar�e�� A) Address��- f �j � r Phonb <br /> [ L A 1-6 1'/.,- <br /> ( ddress D 1 <br /> ko C 11�Ddw.License Nol �J Phone — <br /> Cont�Co <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Cl <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ik <br /> �. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL -'PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom a ❑.Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> a <br /> ❑ Public ❑ Other----- -`+"""❑"Delta" --Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth _ ❑ 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 501 <br /> Depth Filler,.Material.(Below.50'.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO Mo septic system permitted if public sewer is <br /> vailable 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. D Method of Disposal <br /> Distance to nearest: Well Foundation k Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ <br /> Distance to nearest: Well Foundation j Property Line <br /> SEEPAGE PITS ElDepth Size Number <br /> SUMPS t ❑ Distance to nearest: Well Foundation Property Line If <br /> DISPOSAL PONDS ❑ 3 <br /> 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 1} <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 <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 ap licant m call f all inspections. Complete drawing on "rse side. <br /> Title: Date: <br /> Signed '� <br /> I <br /> '- FOR DEPARTMENT USE ONLY i <br /> 46 <br /> Application Accepted by <br /> !/" Date Area 0 2 11 <br /> J�� k J <br /> Pit or Grout Inspectio y Date Final Inspection by Date Date --if <br /> Additional Comments:/267:' <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 ❑ Tracy 83548385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24{REV.I/a 57 3 S a 942�0 <br /> EH 1426 p <br />