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f <br />} <br /> APPLICATION FOR PERMIT . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I <br /> E 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephohe 12091 X466-6781 <br /> ,„p <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> I <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" y <br /> li Job Address _ a /1 N LL Lt Y0 City Lot Size PM <br /> ` �lf• Address0- <br /> Owner <br /> /}A}� s1 � 0` <br /> Owner's Name /J Phone <br /> ContractorAddress 3 License No. <br /> ��i ISS Phone 3� <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑' SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK LSEWER LINES DISPOSAL FLD. 'I" PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA,. CONSTRUCTION SPECIFICATI dl <br /> ❑ Industrial ❑ Open Bottom Alanteca '\Dia. of Well Excavati Dia. of Well CasingDomestic/Private Gravel Pack cyType of Casing Specifications � ��,'zFI Public ❑ Other ❑ Delta Depth-of Grout Seal Type of Grout <br /> I Irrigation �f _Approx.IDepth I I Eastern Surface Seal Installed by 0IV41 _ <br /> Repair Work Done E3 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth I Filler Material {Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION l 1 Wo septic system permitted if public sewer is <br /> available within 200 feet.} <br /> Installation will serve: Residence— Commercial_ Other <br /> 'Number of living units: Number of bedrooms V f <br /> Character of soil to a depth of 3 feet: I y Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of tines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I i Depth Size Number <br /> SUMPS ❑ Distance tri nearest: Well Foundation Property Line -� <br /> DISPOSAL PONDS ❑ I <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 Diltrict. , <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 l <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature j <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." I f <br /> The applicant call or al equir in coons. Complete drawing on rev se side. <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY OJ/7t <br /> Application Accepted by r Date ` I Area <br /> 1�4 <br /> Pit or Grout Ins . <br /> Inspection by Date Final Inspection by ate /1 ! <br /> Additional Comments: - lO G6 <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 6t Manteca 623-7104 ❑ Tracy 635-6365 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK 41 INFO FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> +.EH113-24 IREY.t/n 51 0 /l'�" I� , / <br /> EH 14-28 �f D r <br />