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APPLICATION FOR PERMIT t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT S <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 /> -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, q <br /> Job Address 1 C7 f ��c+ 'm``� City Lot Size . �3�(x 46; PM <br />` Owner's Name -+ OrY !t6 IOs� Address 3� sa����_ `J Phone 116 0y-3 <br /> Contractor Address License No. Phone <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. PRO <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SP IONS <br /> F1 Industrial ❑ Open Bottom ❑ Manteca Dia. xcavation Dia. of Well Casing <br /> E] Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing Specifications <br /> f I Public ❑ Other 4 Delta Depth of Grout Seal Type of Grout t <br /> 1 1 Irrigation rax. Depth I') Eastern Surface Seal Installed by V Repair Work Done Type of Pump H.P ,State.Work Done <br /> Well D tion ❑ Well Diameter Sealing Material (top 50'1 <br /> -� Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I-I 0ESTRQCTIONA tNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other t <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity 1 No. Compartments <br /> 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 /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ - _ -- -a..- .. �- -R-,.._..a,r .. - — - _ - . , <br /> I hereby certify that I have prepared this application and that the work will bedone in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. .1 <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 w6rkman'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 licant t call for aN required inspections. Complete drawing on reverse side. <br /> Signed X Title: 6CLl 'f Date: �?!23 4 7 <br /> FOR DEPARTMENT USE ONLY (n <br /> Application Accepted by f nC`r� _ Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> r � <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-362 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant.- Return all copies to: Environmental Health.Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> + EH13-241REV,1/851 <br /> EH 14-28 (� // <br />