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to <br /> APPLICATION FOR PERMIT, <br /> z SAN.JOAQUI,N LOCAL ,HEALTH DISTRICT. <br /> /} '�1 1601,E. HAZELTON AVE.• STOCKTON, CA <br /> Telephone (26) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM 'DATE-ISSUED _ <br /> `(Complete In Triplicate) <br /> Application is hereby made to the San Joaquin.Local Health District fora permit to construct and/or install the work herein described. This application is <br /> dmade 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 /> r <br /> y /IY <br /> Job Address G°'rc-� ""` 0'U `' =. Gt' ._ � Lot Size PM <br /> G e�L► j1 <br /> 5 <br /> C3� a ��� Phone <br /> Owner's Name _ Addres"s <br /> i r <br /> "Contractor ( u f 5'G,1'�?r�,�. �'�. <br /> (®( t`� ► !i if Address !� LtCense No. 124 3?'?— Phone <br /> F�'� o � <br /> _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 'DESTRUCTION Or <br /> �. DISTANCE TO NEARE IC TANK SEWER LINES, <br /> REPAIR DISPOSAL f OTHER ❑ <br /> J PUMP INSTALLATION'd y <br /> LI <br /> - J "` SAL FLD?" -PROP.,: <br /> FOUNDATIO AGRICULTURE WELL OTHER'WELL PITS/SUMPS <br /> INTENDED USE. TYPE OF WELL PROBLEM AREA RUCTI ffIFICATIONS <br /> ❑ Industrial ❑ Open'136ttom [3-Manteca . e11 Exc Dia,. of Well Casing <br /> O Domestic/Private ❑ Gravel Pack ❑Trac Type,of ;in. <br /> _ Specifications <br /> M l Public ❑ Other elta i Depth of Grout Seal �"`� of Grout <br /> r. .- <br /> I I Irrigation _ _Appr epth i I Eastern' *• Surface.Seal Installed by _ <br /> Repair Work Done ❑ of Pump State Work Done <br /> Well Destructio Well Diameter Sealing}Material (top 50'1 <br /> Depth -`� k�° Filler Material (Below 50') <br /> j TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I DESTRUCTION (No septic system permitted'if public sewer is <br /> F available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other Y I <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---L.. 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 I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS - ❑ <br /> I 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 /> certifies the following: "I certify that in th_Wsc6 <br /> mance of the work for which this permit is issued,:I shall employ persons subject to workman's compensa- <br /> tion laws of <br /> The applica t s�ca*1'1'for all required ins. Complete drawing on r verse side. _ <br /> Signed X Y Title: � � Date: " <br /> FOR,DEPARTMENT USE ONLY <br /> Application Accepted by Date '" `r Area <br /> Pit or Grout Inspection by Date Final Inspection b Date <br /> Additional Comments: f <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 /> FEEINFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED 13Y DATE PERMIT*NO. <br /> e,-9. !. - <br /> EH 14-281REV.tins! 3S �L s <br /> ft"i "?4 Lid V-4 ke.0,0 %II GJYLK6� � <br />