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' APPLICATION FOR PERMIT <br /> r <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 7,1 1601 E. HAZEL T ON AVE,, STOCKTON, CA <br /> Telephone,(209) 466-6781 <br /> r PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> i <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 /> cal Health District. �7 <br /> Job Address ® O City Lot Size 29SI 7 f pM <br /> E <br /> I <br /> Owner's Name b �4-_S Address 2 ��0 ` CLIIr <br /> Phone <br /> L <br /> Contractor Address 0 yy1 Sa 4al <br /> License No. Phone_ 3 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> I <br /> I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL 0TH L� PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CON N SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ MantecaDia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack y Type of Casing Specifications <br /> F] Public f-1 Other F Delta Depth of Grout Seal UV <br /> Type-of-Grout <br /> ! I Irrigation �. ox. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ype of Pump H.P. State Work Done T `� <br /> Well ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material IBelow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION A REPAIR/ADDITION l 1 DESTRUCTION I I (No septic system permitted if public sewer is ` <br /> .- <br /> Installation will serve: Residence— Commercial_' Other available within 200 feet.) <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. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r <br /> LEACHING LINE No. & Length of lines d L Total length/size p <br /> FILTER BED ,.❑ Distance to nearest: ', Well d <br /> —� Foundation 3 Property Line <br /> SEEPAGE PITS l I Depth .-Size Number 1 <br /> SUMPS r� Ll Distance to nearest:' Well Foundation Property Line l <br /> DISPOSAL PONDS ❑ <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 shalt 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:.­".lcertify,that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. - <br /> c <br /> Signed X Title: <br /> (D!) "" � Date; 6 <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted b k <br /> Date ` 4 r�� Area <br /> I <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Date <br /> (oma/� 7 <br /> Additional Comments: .. s <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 <br /> INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> r EH1 <br /> 3-24iREV.I/851 l o �rl� � <br /> EH t4-26 ` _ �� r 7- <br />