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° APPLICATION .FOR PERM& #' 4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r, <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-Mi <br /> I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 - ! "SifI:V\f 6, _ City Lot Size � �PIM a <br /> Owner's Name r Address <br /> Phone <br /> Contractor L LAddress 5U C L T2ti icense No.Ll 1c) Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT EI DESTRUCTION ❑ <br /> PUMP INSTALLATION'-D' SYSTEMIREPAIR"`Cl'-"'-`` OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. I PROP. LINE <br /> FOUNDATION AGRICULTURE WELL; OTHER WELL I PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f <br /> ❑ Industrial ❑ Open Bottom ❑ Malt teca. Dia:_of'Well'Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy "--Type of Casing { ° Specifications <br /> ❑ Public ❑ Other` 0 Delia Depih W� rout Seal f Type of Grout <br /> ❑ Irrigation ---Approx. Depth I❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type ofPump ; J H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing_Material.{top:,50'1 <br /> Depth Filler!Material(Below 501 �.' r,• ' � =� � 't <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U,,M STRUCTION'❑ fNo septic system permitted if public sewer is <br /> 1 ;available within 200 feet:), <br /> Installation will serve: Res}dente t�Commerciai Other f ' <br /> Number of living units: 1 l Number of bedrooms <br /> pt�ry� A <br /> Character of soil to a depth of 3 feet: �l�F-7 Water table depth <br /> SEPTIC TANK ❑,, Type/Mfg Capacity l No. Compartments <br /> PKG. TREATMENT PLT. ElIT , <br /> # t Method of Disposal <br /> Distance'jo nearest: Well F un ation PropertyLine <br /> I i 1 l <br /> LEACHING LINE M—No. & Length of lines ' F 'l*4 tTotallength/size <br /> FILTER BED ❑ Distance to nearest:' Well Toundation; 1 +Property Line - <br /> I i ) � { <br /> SEEPAGE PITS ❑ Depth Size y �" �k Number I t <br /> SUMPS 02--Distance to nearest:. Well ,r Foundation 'k'A-b Property Line <br /> DISPOSAL PONDS ❑ I f f' <br /> hereby certify that I have propered`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. 7 <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 /> rtifies 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 /> do ws of California. , <br /> The app i mus call fo�Ilre d ins tions. o pl a yawing on verse sid,. <br /> Sign. _ A- <br /> le.: Date: <br /> FOR PARTMENT USE ONLY / <br /> Application Accepted by t[ Date / `1'1 r a Area `,S <br /> Pit or Grout Inspection by Y Date �'�1 Final Inspection by Date l <br /> Additional Coments: <br /> 11Stk 466-6781 LI Lodi 369-3621 El Manteca 823-7104: '© Tra r 835 r��G�� yy` r <br /> m <br /> Applicant- Return all copies to: Environmental Health PermiflServices 1601 E�Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED 1C K� �yyrREC��EIVE�D BY DATE PERMIT"'N0. <br /> + EH 1428 EH 13-241REV,i/e57 <br /> . J o`-�'r ► _ ` P� ` <br />