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r .. a :x�-;.,.: �.,�--.y i�+1�►.r..t,.. ,g. - <br /> . <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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. <br /> Job Address 6 <br /> rrt City CTall,�Lot Size PM <br /> Owner's Name` 1-�V CIL-L a tall Address s��� <br /> M,,C Phone <br /> i <br /> Contractor Address IOD E1D0 ,. <br /> License No.44Z–16162phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ `]1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �} <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA, I CONSTRUCTION SPECIFICATIONS xxx <br /> ❑ Industrial 1iOpen Bottom ❑ Manteca '_Dia. of Well Excavation <br /> - r Dia. of Well Casing <br /> 1-1 Domestic/Private ❑ Gravel Pack 13 Tracy w Type of Casing <br /> LJPublic ❑ Other Specifications <br /> ❑ Delta Depth of Grout Seal <br /> ❑ Irrigation __p, Type of Grout <br /> ---Approx. Depth Cl Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. <br /> State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth .Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO a septic system permitted if public sewer is <br /> Installation will serve: Residence, Commercial— Other f available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> i Water table depth ' <br /> SEPTIC TANK ❑ Type/Mfg �' F Capacity <br /> PKG. TREATMENT PLT. Cl No. Compartments <br /> 1, *, 1 Method of Disposal <br /> Distance to nearest: Wel! Foundation 'Property Line <br /> , <br /> LEACHING LINE ❑ No_ & Length of lines Total length/size y <br /> FILTER BED ❑ Distance to nearest: Well Foundation r <br /> r i Property Line a <br /> SEEPAGE PITS ❑ Depth Size <br /> Number <br /> SUMPS ❑ Distance to nearest: Well Foundation <br /> r 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 /> The applicant s all f r I requir d inspections. Complete drawing on reverse side. ` <br /> Signed X <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY /� <br /> Application Accepted b Date�� Z f <br /> Area <br /> Pit or Grout Ins <br /> pection by �� rr Date Final Inspection by � Date <br /> Additional Comments: /�v /�) Ira (j h 1 L ✓ L j 1J !' <br /> El Stk 466-6781 ❑ Lodi 369-3621 ❑ ❑ Trac 835.6385 Manteca 823-7104 y / <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 CK <br /> INFO / CASH RECEIVED BY DATE PERMIT'No. <br /> + EH 13-241REV. <br /> EH 1428 �/J s �fiy <br />