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`# APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <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. <br /> b Address Z 1 ko 6 City Lot Size _2? It PM <br /> 111 �r �i <br /> wner's Name 1 A IBJ ��_`_.__ Address _'z!, 3,Srn �-D-fg ..t �_ Phoney J a 19 <br /> Contractor St. Address License No. Phone <br /> F WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t� <br /> DISTANCE TO NEAREST: SEP SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION _AGRICULTURE WELL OTHER WELL PITS/SUMPS C� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of avation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f'1 Public n Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation _.-Approx.i Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50'I <br /> Depth I Filler Material (Below 50') _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence J Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:I 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 y ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line j <br /> I <br /> SEEPAGE PITS `' l 1 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 /> 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." t <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> f t t 1J <br /> xSigned X Title: f <br /> Date: <br /> FOR DEPARTMENT USE-ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 W i <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 <br /> FEE INFO AMOUNT DUE f AMOUNT"REMITTED ASH ECEIVED BY DATE PERMIT'NO. I� <br /> + EH13-24(REV.I/K5) ��� 2( .- <br />