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F t r:- , <br /> APPLICATION-FOR PERMIT <br /> t 4� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> " Telephone 12091 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 LJ 1 N ti� HIJP l City Lot Size PM <br /> 122-0 tQ1 <br /> Owner's Name�✓ f91 1 /tea 1�' ft8re`sse Phone <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> s DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL /SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTi (CATIONS <br /> E ❑ industrial r ❑ Open Bottom ❑ Manteca ell Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ T Type of Casing Specifications <br /> d <br /> 1 I'] Public f 1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> 1 1 Irrigation rox. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P—. State Work Done <br /> e Well Des an ❑ Well Diameter Sealing Material )top 50') <br /> `` Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 -REPAIR/ADDITION [.I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> 1 <br /> 1 <br /> Number of living units: Number of bedrooms ' <br /> of Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK C7' 'Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ £ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line , <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line t! <br /> i <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS ❑ 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 /> 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 law's 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 campensa <br /> tion laws of California." <br /> licant must call r I required ins ctio ns. Complete drawing on reverse side, /f A— <br /> Signed X Title: vo. Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date �/r� �— Area <br /> Pit or Grout Inspection by Date Final.Inspection by /Date <br /> Additional Comments: �/`� a !"/V l)_ G&11 i /1k <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 F ❑ Tracy 5-6385 q,J per- /yfrr- <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton ve., P.D. Box 2009, Stk., CA 95201FEE <br /> S,S <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> ♦ EH 13-24(REV.1R6) 5S . oc i <br /> EH 14-26 �� <br />