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y <br /> I <br /> i <br /> APPLICATION FOR PERMIT <br /> /J SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA � <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> j <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 /> Local Health District. <br /> Job Address A'SAIT'yi City � rc f Lot Size PM <br /> Owner's Name � �U i F n16JCc'q Address k0i�Z^+ 0A14 Phone <br /> ContractorAddress` f <br /> � � License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ r SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE NEAREST: SEPTIC TANK SEWER LINES. DISPOSAL FLD PROP. LINE <br /> FOUNDATION AGRICULTUk WELL R WELL PITS/SUMPS. <br /> INTENDED USE OF WELL PROBLEM AR NSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ElOpen Bo Elca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications <br /> F1 Public ❑ Other ❑ De Depth of Grout.Seal Type of Grout _ — <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by. _ <br /> Repair Work Don Type of Pump H.P. State Work Done_ <br /> W�I[IDe tion ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l J REPAIR/ADDITION L 1 DESTRUCTION (No septi stem permitted if public sewer is C <br /> available within et.) <br /> Installation will serve: Residence_ Commercial_ Other. <br /> k. <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: - - Water table depth <br /> El SEPTIC TANK Type/Mfg Capacity ® No. Compartments <br /> k 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 /> Of <br /> SEEPAGE PITS Depth Size _ _ Number <br /> k SUMPS Ll 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 /> 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 must�call <br /> for all required inspe tions. Complete drawing on reverse side. r� Q <br /> Signed X�� L S. tda Title: S im— <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> I) Application Accepted by Date ° Area <br /> I Pit or Grout Inspection Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 • 'b Tracy -835-6385 <br /> Applicant - Return all copies for Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK EIVED B DATE PERMIT NO. <br /> O ASH <br /> INF <br /> +.EH -241REV.iiNs) <br /> 14 <br /> EH 14-28 �7 ��4••JJJ ttJJ d� (J <br />