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*� 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 a <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 ) 3 `! Rls oL City Lot Size IOS X ! CIS PM <br /> Owner's Name �` _A� L 4 Address Oil r- M Af4 qA t r_ Phone q-77-3) 4 G <br /> Contractor Cr 1 _Address �3 Zt4 t'n l iLIC License No. 3 5 $Q�0 Phone 3`a <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: AK SEWER LINES OSAL FLD. PROP. LINE <br /> FOUNDATIO AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I <br /> INTENDED USE TYPE OF WELL PR M AREA CONS TION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Ia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tra a of Casing Specifications 1 ,, <br /> ❑ Public n Other Delta Depth o ut Seal Type of Grout <br /> I I Irrigation x. Depth I I Eastern Surface Seal Insta <br /> Repair Work Done ype of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material iBelow 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION f I DESTRUCTION (No septic system permitted if public sewer is <br /> available 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. ❑ 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 <br /> SEEPAGE PITS 1 1 Depth Size Number <br /> SUMPS 0 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 i <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." t <br /> The applic t cal! i) r qu'a in ctions. Complete drawl �ys Signed X # Title: Date: j <br /> i <br /> ^. {� FO PARTMENT USE ONLY <br /> Application Accepted by __�.�{ w 1V� . �, cSri.rvY�C.n&n.i% Date Area /Y <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> a <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 5 1 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Elox 2009, Stk., CA 95201 <br /> I <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATEPERMIT-N0. <br /> + EH 13-21 I REV.I/w 51 <br /> EH 14-28 <br />