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. �,• APPLICATION FOR PERMIT <br /> J SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone {209) 466-6781 � U'�`t�`' <br /> PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED BC qt*9 <br /> M f (Complete in Triplicate) N 0 <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. 1661 for well/pump and the Rules and Regulations of the San"Joaquin <br /> Local Health District. <br /> Job Address �l� �'4 '�� �� __... ... City �f. Lot Size T) Da PM <br /> Owner's Name!moi -,�q� /7 a'Jf1lS Address Q ®!/ (,� _ Phone 114108, <br /> Contractor ,Z e 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 S R LINES ° DISPOSA PROP. LINE <br /> FOUNDATION AG <br /> TURE_WELC'A, O WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA NSTRUC SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. ell Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy o as <br /> Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ irrigation ____App x. Depth ❑ Ea n 1- -Surface Seal Installed by <br /> r c _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done , <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 S <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> IN 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 /> i <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 171 Method of Disposal <br /> Distance to nearest: Well Found ' Property Line <br /> f <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> f <br /> FILTER BED ❑ Distance to nearest: We Fou�%_ <br /> Property Line <br /> i <br /> SEEPAGE PITS ❑ Depth I 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 laws of California."Contractor's hiring or sub-contracting signature <br /> F 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 /> 1 <br /> plicant must call for ail requir inspec s. Complete drawing on reverse side. <br /> r <br /> Signed` <br /> Title:_y.16/ Date:,L-2 2 4`2 <br /> FOR DEPARTMENT USE ONLY <br /> I Application Accepted by S Date Area <br /> Pit or Grout Inspection Date _ Final Inspect`ion�bbv C pat <br /> �_p <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 104 ❑ 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 /> a FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO A <br /> i <br /> EH 13-24(REV.)/8 5) 36-00 <br /> �EH 1428 I`�/ <br />