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v APPLICATION FOR PERMIT / <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT C _. <br /> �- 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 3 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> s 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address <br /> Lot Size PM <br /> I r <br /> i <br /> Owner's.Name Address Pho?X2— Q <br /> Q <br /> " Contractor f Address '. Licens �� Phoma <br /> TYPE OF WELL/PUMP:. {. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LI <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION S ATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia._ of xcavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack. ❑ Tracy _ e of Casing * Specifications <br /> fl Public ❑ Other f� Den Depth of Grout Seal t Type of Grout _ <br /> I I Irrigation �.Approx D Eastern Surface Seal Installed by ! <br /> P Repair Work Done ❑ T ump <br /> H.P. State Work bone <br /> Well Destructio Well Diameter Sealing Material /top 50'1 <br /> Depth I Filler Material (Below 50') <br /> TYPE OF SEPTIC-WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTIO (No septic system Ae <br /> ermitted it public sewer is <br /> vailablet.) <br /> Installation will serve: Residence� Commercial� Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: — W +SEPTIC TANK ❑ Type/ fgCapacity NosPKG. TREATMENT,IPLT. ❑ MealDistance to nearest` Well Foundation Property j <br /> } t*_ <br /> LEACHING LiN4 ' ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: ' Well Foundation <br /> e r Property Line i <br /> SEEPAGE PITS 1.1 Depth Size Number <br /> SUMPS r hl Distance to nearest: Well Foundation. Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared thisiapplication 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." 1 <br /> The applican ust call for all required ins ctions. Complete drawing on rev a side. <br /> s <br /> Signe —Y.=..�� <br /> Title: l�Cl�t!��� Date-7— <br /> FOR <br /> aterFOR UEPARTMSENT USE ONLY <br /> A` <br /> ` <br /> Application Accepted by r ' i-'°'`j. `S 1 7— <br /> Area <br /> t Date 'moi <br /> Pit or Grout Inspectio�byi <br /> Dt ` Final Inspection by _ZDateAdditional Comments <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 I <br /> FEE AMOUNT DUE } AMOUNT REMITTED CK <br /> INFO i CA H RECEIVED BY DATE PERMIT'NO. <br /> r + EH 13-21/REV,I/n 51 u <br /> EH 14-28 _ .. r 7 f•." ��t/C/ 3 <br /> H <br />