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APPLICATION FOR PERMIT <br /> F , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> I � <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 /> 1 Local Health District. <br /> s <br /> I Job Address City Lot Size/4c,r1r <br /> / PM <br /> Owner's-Name ".� - F48 A A Address J � Phone .sem'— <br /> �� 4 <br /> Contractor ODA41Z Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br />{ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> fl ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public <br /> 171 Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation _Approx.,Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump -rrH.P. State Work Done _ A ' <br /> Well Destruction ❑ Well Diameter 4 Sealing Material (top 501 <br /> Depth Filler Materia; elo i ,- le,+ + _ VN <br /> k TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDIT! ` STRUCTION I 1 INo septic system permitted if-public sewer is <br /> available within 200 feet.) <br /> I Installation will serve: Residence!k Commercial_ Other " ,,L� i <br /> Number of living units: Number of beds o s /` ;.� <br /> Character of soil to a depth of 3 feet:i OI_e 1A <br /> table depth <br /> SEPTIC TANK ❑ Type/Mfgt Capacity M No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1 Method of Disposal <br /> Distance to nearest: Well _Foundation Property Line <br /> LEACHING LINE No. & Length of lines IVA Total length/size <br /> FILTER BED ❑ Distance to nearest: Well /00 Foundation gc 0. Property Line <br /> SEEPAGE PITS [t Number <br /> SUMPS 19,Distance to nearest:' Well 100 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 /> f rules and regulations of the San Joaquiri Local Health District. <br />{I 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 ryMst call ford ruir ins ions. Complete drawing on reverse sidsp. <br /> Signed X ! Title: _�.13 ►�/"t-lit Date: <br /> FOPARTMENT USE ONLY <br /> it Application Accepted bye Lac+ _ C Date ` i� Area <br /> Pit or Grout Inspection by Date Final Inspection by �' IJP` Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 0 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 /> k INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY PATE PERMIT NO. <br /> +.EH t824]REV.r _�� C� <br /> EH 14.26 v �!+t�J 1'� i O` 3 �. <br /> i <br />