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,. APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ,� 0 <br /> 1601 E. HAZELTON AVE. STOCKTON CA C� ,+ <br /> Telephone !2091 466-6781 N O //QLJT I <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED I_ _ .(� l� r. <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 app is ion 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 __5_l ? I CJ_Pt I P-2 City i� Lot Size PM <br /> Owner's Name GnU&I kE6 L.1 Address Phone <br /> Contractor Address o s c "tbcense N6.47&- 9Phone f tf <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION" AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE ! TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrials +, ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 't Specifications <br /> Fl Public.,/ t.{ f ❑ Other Ll Delta Depth of Grout Seal ; Type of Grout _ <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by 1 <br /> Repair Work Done EJ--Type,of..Pump.-. H,P. State Work Done_ } <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 rJ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION I 1 DESTRUCTION I i 1 tem permitted if public sewer is <br /> available within 200 feet.} <br /> Installation will serve: Residence mercial_ 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 I ❑ Type/MfgCapacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ + s ! Method of Disposal <br /> I Distance to nearest: Well Foundation Property Line <br /> tt. <br /> LEACHING LINE ❑ No. & Length of lines ' Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> r <br /> SEEPAGE PITS I I Depth Size yNumber <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 /> emp oy any parson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> cent ie a 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 1 o alifornia." j <br /> The applica m all f a re u" d ins c ions C p drawing o ver Q <br /> Si Title: Date: T U <br /> F EPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by / Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 1 -241REV,tixsl z­o <br /> EH 144-28 � 1 l <br />