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4 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 = <br /> PERMIT EXPIRES 1 YEAR FROM DATEASSUED <br /> (Complete in Triplicate) <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. I; <br /> l �d <br /> r Job Address ' / '" ! City Lot Size PM <br /> 1 §. /p <br /> y <br /> Phone <br /> Owner's Name Address, � <br /> is <br /> i A�x <br /> Contractor dress ; (cense No. Phone <br /> TYPE OF WFLLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> ' <br /> PUMP INSTALLATION-E -- ..._.r^---S TEM-REPAIR--O — OTHER-O---. --^ `� <br /> t u�b <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS <br /> j INTENDED USE t (TYPE OF WELL PROBLEM AREA C S RUCTION SPECIFICATIONS <br /> ❑ Industrial © Open Bottom ❑ Manteca ia. Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type f Casing Specifications p <br /> M Public Ci Other ❑ Delta Dept of Grout Seal " Type of Grout �} <br /> r <br /> I I Irrigation t _.-Approx. Depth i I Eastern 5uiface Seai Installed by _ 0 <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 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIR/ADDITION I IF DESTRUCTI N I 1 (No septic system permitted if public sewer is pp� <br /> avails with( 200 feet.) I N <br /> Installation will serve: Residence Commercial Other <br /> 1r Number of living units: Number of bedrooms NN <br /> f Character of soil to a depth of 3 feet: Water table'depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity ­­­.Compartments <br /> PKG. TREATMENT PLT. I7 i` Method of Disposal <br /> Distance to nearest: Well Foundation Property.Line <br /> LEACHING LINE ❑ �' No. & Length of lines 1 Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I'I Depth Size Number <br /> "SUMPS L] Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I <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 in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such nienner 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 works for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." r ' I f <br /> The applica t must call f required nspections. Complete drawing on reverse side. <br /> Signed X Title:_ '-'L� � t. .. Date: ` r <br /> 10V 7 <br /> � ��F� DEPARM <br /> TENT USE ONLY <br /> 4 ~ t 4 <br /> Application Accepted by Date — Area <br /> 4f k y <br /> Pit or Grout Inspection by 1 '" ' Date Final Inspection by J' & ' Date � e <br /> Additional Comments: ' <br /> ❑ Stk 466-6781 ❑ Lodi 1369-3621 0 Manteca 823-7104 ❑ Tracy 835=,W85 t <br /> Applicant - Return all copies to: Ehvironmentaf"Health Permft/Services 1601 E. Hazelton Ave., P.O. 80x.2009;Stk:, CA 95201 <br /> CK <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY J DATE PERMIT'NO. <br /> +.EH 13-24(REV.1 i n 5) �� �} 1�7 <br /> EH 14-28 \yV\ `'Vit n C)^ 1 ! <br />