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S <br /> ;J APPLICATION FOR PERMIT <br /> M C E I V <br /> $AN JOAQUIN LOCAL HEALTH DISTRICT RE <br /> r 1601 E. HAZENAVE,, STOCKTON, CA <br /> } ' Telep nes(206) 466-67$1 DEC 6 19$ <br /> uE R <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISS ��1}�,iQNME�iTAL HEALTH <br /> (Complete in Triplicate) PERE,11iT/SERVICES <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 />� Lac I � <br /> Job Address <br /> i -7Z City t Size PM <br /> Owner's Name Address <br /> • Phane � ~ <br /> Contractor <br /> 1 dress 1�� Ba \ 1 License No. Phone_ <br /> TYPE OF -/PUMP: ----N W-WEL-L—O —WELL- ,.,...,,„DESTRUCTION- L1 <br /> PUMP INSTALLATION 11SYSTEM REPAIR &I--- OTHER 11 , <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL0. r PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Boti.tom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing <br /> ) omesticlPrivate Cl Gravel Pack ❑ Type of Casing 9 Specifications _ <br /> f� Other ❑ Delta Depth of Grout Seal„ Type of Grout <br /> ! t`1 Public � <br /> A rox. Depth t I E stern Su ce Seal Installed'by' <br /> I i Irrigation W___ <br /> ��� PP P. <br /> Repair Work Done L type of Pump H•P �� State WorkDone <br /> Well Destruction ❑ Well Diameter Sealing Material itop 50 <br /> Depth Filler Material 16elow 501 <br /> f TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION l I DESTRUCTION t I INo septic system permitted if public sewer is 1 <br /> available within 200 feet.) J <br /> Installation will serve: Residence_ Commercial— Other �. <br /> Number of livin units: Number of bedrooms <br /> 9 <br /> Character of soil to a depth of 3 feet: Water`ta I depth <br /> j 30 S c i{t r- � i <br /> SEPTIC TANK ❑ Type/Mfg Capacity �'t�No.-Corripartments <br /> L..v Method of Disposal <br /> f PKG7 TREATMENT PLT. 0 ... <br /> Distance to nearest: Well Foundation Property Line r <br /> j 17 <br /> LEACHING LINE D No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size _ Number <br /> I <br /> SUMPS Ll Distance to nearest: Well Foundation Property Lie <br /> DISPOSAL PONDS ❑ 1 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San JoaZluin county ordinances, state laws, a <br /> rules and regulations of the San Joaquin Local Health Di1trict. <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 n In suc anner as to bec a subject to workman's compensation laws of California.” Contractor's hiring or sub contracting signature <br /> Corti t following: "I ce y that tri e o an the work for which this permit is issued, I shall employ persons subject to workman's compensa r <br /> tion law of Califo ia." i <br /> The ap Iicant m t r all re Com to drawing on std <br /> Signed <br /> Title: t Date: <br /> iOF FOP DEPARTMENT USE ONLY <br /> Application Accepted by Date ^�_ Area / pj <br /> Pit or Grout Inspection by Date Final Inspection by Date .Z <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ 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 /> f <br /> CK 4 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY PATE PER N0. <br /> 1 INFO <br /> +.EH 53-24 IREV.l/n 51 <br /> BIZ �q <br /> EH 14-26 <br />