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t I <br /> I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 jr.p v.•�lA.+JI. <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. 18&2 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address �- 141'0. -C City.51i2CLot Size /50. 7S_ PM <br /> -Sroe K7cOA✓ �r�_ <br /> Owner's Name ►/�1� 0- VE ddress ✓ Phone -�+ <br /> Contractor Address ZW1 i<.Y License No.-.% aPhl e <br /> TYPE OF WELT./PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION Cl SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P <br /> FOUNDATION AGRICULTURE WELL OTH PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO ON SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack acy Type of Casing Specifications <br /> f`i Public n Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation pprox. Depth I I Eastern Surface Seal Installed by _ <br /> Repair Work Done Type of Pump H.P. State Work Done _ <br /> Well Des on ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') v <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTIO (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence__-_ Cominercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK X Type/Mf Capacity 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 11 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> I <br /> SEEPAGE PITS l I Depth Size Number i <br /> SUMPS Cl 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." ° / <br /> lira ust 11 for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: tN-1X/'f1U 2/2c97`NE12— Date: <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> Application Accepted b Date Area <br /> Pit or Grout Inspection by �1 Date /Final Inspection by Date <br /> Additional Comments: <br /> D 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 /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO CAS q1 <br /> + W13.241REV.1/95) 00 !36,COP <br /> d <br /> EH 14-26 iii <br />