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II � <br />`•1Y Viii' - <br /> II r� � <br /> APPLICATION FOR PERMIT <br /> 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> q - - <br /> HAZELTON AVE,, STOCKTON, CA <br /> 1,601'E. <br /> 'I it sTelephone 52091 466-6781 <br /> R . <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IComplete 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 Q �j { <br /> !I `-'� City ' Lot Size r x` .0 <br /> 1i PIM <br /> p Owner's Name Address Phone <br /> Contractor's Name License No. L ,�.J Z, Phone 1� 310 - <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. PROP. LINE <br /> �I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF,WELL't. PROBLEM..AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wel! Casing <br /> ❑ Domestic/Private ❑ Grave! Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other } ❑ Delta 3 Depth of Grout Seal Type of Grout <br /> li ❑ Irrigation --Approx. Depth )❑ Ea tern � Surface Seal Installed by <br /> JiRepair Work Done ❑ Type of Pump H.P. t' `" State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50')`� ' <br /> - r <br /> Depth " �'• +..Filler Material (Below 50'1 �� <br /> M1t6 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION'❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is <br /> 4 available within 200 feet./ <br /> Installation will serve: Residence Commercial_ Other N <br /> `�. Number of living units: Number of bedrooms _ <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK A Type/Mfg'— Capacity_.IV 0-a No. Compartments <br /> ;i PKG. TREATMENT PLT. ❑ Method of D's oral <br /> Distance to nearest: Well 1�"*Foundation_ 0 Property Line <br /> II LEACHING LINE No. & Length of lines _ ' Total length/size <br /> FILTER BED ❑ Distance`to nearest: a kWell Foundation _. Property Line <br /> u SEEPAGE PITS Depth •A. „__Size / Number <br /> SUMPS ❑ Distance to nearest:,.' ' WellOr Foundation L <br /> —� � Property Line <br /> DISPOSAL PONDS ❑ <br /> II 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 /> ,I 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 /> 11 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 fallowing:"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 /> il -The applicant must call for all requir nspections. Co plate drawing on reverse side. <br /> .i Signed SigTitle: fly t <br /> -- Date: <br /> FOR DEPART NT USE ONLY Q <br /> :, Application Accepted by Date <br /> ]� I <br /> ii 0o Grout Inspection by Date — Final Inspection by; Date <br /> Additional Comments: <br /> II ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> II Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> I� I <br /> INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT`NO. <br /> 11 <br /> + EH 13.24(REV.1f118313�� Jam, p <br /> EH 14_-26 _ {{{ 1 1 <br />