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1 <br /> 4 APPLICATION FOR PERMIT <br /> 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 F ❑t1 <br /> 11F��� ,1 �'� <br /> (Complete in Triplicate) <br /> the work hetetA 'his application is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct r 1i4s, ," ;u !„ <br /> ourgD end 1j}e Ruiti*W regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for .. �t� <br /> Local health District. / <br /> Job Address <br /> 30 ifr,>t [�/plfcL City dt/ Lot Size PM <br /> O� Address /J �ln�G G � Phoner <br /> Owner's Name 0,0.0— <br /> Contractor Address <br /> ,� Get! Ate/ License N 137 Phone-??7--?421-7 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER EJ <br /> DISPOSAL FLO. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> 2 PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I NDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC TIONS <br /> Industrial El 0 Bottom, Ll Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private Gravel Pack Cl Tracy Type of Casing f — Specifications <br /> _the !/7r Cl Delta Depth <br /> C of Grout Seal Type of Grout <br /> i l Public > /kms <br /> E I Irrigation —.Approx. Depth l I Eastern Su ce Seal Installed by <br /> Repair Work Done 0 Type of Pump -r H.P. State Work Done C..i <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 50'1 – <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION i l DESTRUCTION i I (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other— <br /> Number <br /> ther Number of living units: Number of bedrooms O <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. L] Method of Disposal <br /> t Distance to nearest: Well Foundation Property Line r <br /> 731 <br /> i . <br /> i <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line' <br /> SEEPAGE PITS I"1 Depth Size Number <br /> SUMPS C1 Distance to nearest: Wel Foundation Property Line <br /> DISPOSAL PONDS M. <br /> I. hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stateta . <br /> rules and regulations of the San Joaquin Local Health Di§trict. 'rNIV <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work f }, fit§Rermn is rssu@d$`��not <br /> ,Q oT s�.`,tif-rrtng 9 9 <br /> employ any person in such manner as to become subject to workman's compensation laws of Ca a ' laid h sub co ragun si nature <br /> 1' -� u e O C. s compensa- <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued ��ersb C1s1i(,. <br /> tion laws of California." - ts. <br /> The applicant must call for I re ud nspections. Complete drawing on reverse side. �— <br /> Signed X z Title: 6 / Date: <br /> �• _ FOR DEPAR MENT USE ONLY <br /> Application Accepted by , �������� Date Area ����qq <br /> t Pit or Grout Inspection by Date a' T Final Inspection by D/ateo'.,_�o! <br /> A <br /> Additional Comments: �'� �~G � `�h� / $ 9 G <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 3-7104 ❑ Tracy. 835 5 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> f <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> iNFp y <br /> +.EH13-24(REV.I 115) <br /> EH 14-28 <br />