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• j_ � <br /> r <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 DATE ISSUED <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. <br /> Job Address __ l a <br /> City Lot Size PM <br /> Owner's Named ICY_ !�,]r 1 (}D k1r Address P�iM Ci <br /> � � Phone <br /> Contractor.�,R_LIF Address <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ <br /> STRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LI S <br /> DI OSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTUR WELL THER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CON RUCTI SPECIFICATIONS <br /> ❑ Industrial Li Open Bottom ❑ Manteca Dia. of Excavation <br /> ❑ Domestic/Private ❑ Gravel Pack El Tracy T Dia. of Well Casing <br /> Type Ca ' g Specifications <br /> ❑ Public ❑ Other ❑ Delta D h of Gro Seal <br /> ❑ Irrigation __Approx. Depth ❑ Eastern urface Seal Ins lied by Type of Grout <br /> Repair Work Done ❑ Type of Pump H p <br /> State Work Done_ <br /> Well Destruction El Well Diameter aling Material (top 501 p, <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION <br /> ,1 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Installation will serve: Residence— Commercial_ Other available within 200 feet.) <br /> Number of living units: —.I%— Number of bedrooms <br /> Character of soil to a depth of 3 feet: f <br /> SEPTIC TANK ElType/Mf r, Water table depth <br /> Type/,Mfg Capacity 10—rl No. Compartments 'Z^ <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well 00 �-$r2 Method of Disposal <br /> — Foundation + -} <br /> — Property Line �a_ <br /> LEACHING LINE No. & Length of lines y <br /> Total length/size <br /> FILTER BED ❑ DisWpce to nearest: WeIIS b 4 <br /> �_ Foundation_a..1Z--0 L Property Line LAS t_0 <br /> SEEPAGE PITS ❑ Qepth _ I a t Size <br /> SUMPS ©/ y '� 1� �— Number <br /> Distance to nearest: <br /> Well—aSi0'- Foundation--.;L Pro <br /> DISPOSAL PONDS Elparty Line _1Qb= �+ <br /> I hereby certify that 1 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 <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 require in/pget' Complete drawing on reverse side. <br /> Signed X ^ b <br /> Title: �— d—y� <br /> Date: <br /> A FO EPARTMENT USE ONLY p, <br /> Application Accepted by ��. �A� .o�.... r••. Date �^V� <br /> (� Area <br /> or Grout Inspection by =4• •—Date 57 Final Inspection by <br /> Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT'N0. <br /> + EH 13-24(REV.1/e s) G i y �r,�� <br /> EH 14-28 G./ �/ �^ ^7 /7S <br />