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u <br /> APPLICATION FOR PERMIT <br /> �� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE.', STOCKTON, CA <br /> Telephohe {209) 466-6781 <br /> PERMIT EXPIRES 1YEAR 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. ,�]I �{ <br /> 2—45Z 0 Y <br /> Job Address ab.y �t Size � Rte"M <br /> T Y <br /> rCaA, (C( <br /> Owner's Name Address Ph e <br /> Contractor UJ Ke+ d s u` Licerhone <br /> TYPE OF WELL/PUMP: No WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION J <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE 9Q.) <br /> FOUNDATION AGRICULTURE WELL - OTHER WELL P1T5/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 EI Other 17 Delta Depth of Grout Seal Type of Groumm-�b.-I _ <br /> I I Irrigation —.Approx...Depth I i Eastern Surface Seal Installed by _ <br /> i <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction Well Diameter,(. Sealing Material Itop 50') <br /> Depth Filler Material f8elow 50'1 �I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION {-I DESTRUCTION I I fNo septic system permitted if public sewer is <br /> j I available within 200 feet.) <br /> installation will serve: Residence i Commercial— 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 ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property.Line �y <br /> T <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> t <br /> SEEPAGE PITS l I Depth I Size_ Number <br /> SUMPS Cl Distancetonearest: 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 D3trict. <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." Contractors hiring or sub-contracting signature <br /> certifies the following: "1 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 a us all for all quired inspections. Complete drawin on reverse 1de. <br /> fid X itle: <br /> neL1*' , �U"�`� Data: )� L <br /> FOR DEPARTM NT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by s1, Data u! Final Inspection by /i-' ' Dat I(,- # <br /> Y <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 /> FEF AMOUNT DUE' AM UNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> +.EH 13-24 iREV:1/H s) <br /> `-' <br /> EH 14-28 .�-�--� •_-�-- a Is �-•, <br />