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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA � oz37—/,X"- 7¢ <br /> Telephone (209) 466-6781 <br /> 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 C. AVI—gI f City Lot Size PM <br /> Owner's Name daw zAddress 4 4 :5/9 <br /> ` ) � Phone <br /> Contractor/0',�G!//� �N � � Asj�y �3 <br /> zR 1,W License No. l Phone J <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. LENS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> © Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> FI Public n Other Cl Delta Depth of Grout Seal Type of Grout _ <br /> 1 I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by \ <br /> Repair Work Done ❑'", Type of Pump .1 H.P. State Work Done <br /> Well Destruction ❑ Well Diameter til". Sealing Material {top 50'1 'eB4 C <br /> 'rte Filler Material (Bel'Ow-50'1 <br /> Depth, � d:s <br /> TYPE OF SEPTIC WORK: -NEW INSTALLATION I i REPAIR/ADDITION I 1 DESTRUCTION f I (No 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 Y <br /> Character of"soil'to a depth of 3 feet: - Water table depth <br /> SEPTIC TANK p Type/Mfg Capacity ; No. Compartments <br /> PKG. TREATMENT PLT. ❑ -, Method of Disposal <br /> Distance to nearest: Well Foundation_ _ Property Line <br /> LEACHING LINE D No. & Length of lines Total length/size <br /> FILTER BED D Distance to nearest: Well `"foundation Property Line <br /> SEEPAGE PITS i I Depth Size Number ?' <br /> SUMPS Cl Distance to nearest: ­4iWell Foundation Property Line <br /> DISPOSAL PONDS ❑ "- = <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin cdunty 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,l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicantI req tions. Complete drawing on revers ide. <br /> Signed X—= <br /> Title: Date: ' <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date rea <br /> Pit or Grout Inspection by Date Final Inspection by� Date---L�--l� <br /> Additional 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 <br /> o <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH1424fREV.i/H5l � /���� r✓S�I ' <br /> EH 14-28 r�'^ <br /> G / <br />