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i APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED;1 = 0-1 10 0 1 <br /> (Complete in`Triplicate) <br /> . .•: - f-•.:.�,+.y,.. -�c i,: :- _.., :Y -.r,.. <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 ar;d Regulations of the San Joaquin <br /> f Local-Health District. ,,yr t r _ r <br /> Job AddressCity r �+} <br /> j Loi Size # PM <br />! Owner's Name TC t l (�"lA i2 SA Address <br /> ST .Phone J�� <br /> Contractor 141 H SA t3 ddress fo 'Oo,C•U!e S P <br /> cs� �fWo <br /> License No.`„e's�/'��/� hone <br /> TYPE OF WELL/PUMP: 1 NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMPNL <br /> ,,✓✓' STALATION ❑ SYSTEM REPAIR ID OTHER ❑ <br /> DISTANCE 70 NEAfiEST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LI <br /> NE <br /> FO AGRICULTURE WE1.LL OTH PITS/SUMPS <br /> INTENDED.USE, ,,,_TYPE-OF WEL4— <br /> PROBL-EM- <br /> f <br /> ION-SPECIFICATIONS--, <br /> • -❑ Industrial ❑ Open Bottom ❑ Mantec Dia. of Well xca <br /> ❑ Domestic/Private 1-1Gravel Pack Dia. of Well Casing <br /> y Type of Casing ications <br /> ❑ Public roc❑ Other ❑ Delta f--'"Depth of Grout Seal ' <br /> ❑ Irrigation m* l Type of Grout \ <br /> prox. Depth ❑ Eastern � ��Surfi4ce Seal Installed by .- <br /> Repair Work Done ype of Pump': H P " ,' <br /> State Work Done i <br /> Well Destruction l] Well Diameter Sealing M ial (top 50') <br /> {j <br /> Depth p � Filler Material {Below 50') <br /> TYPE OF SEPTIC WORK: NEWINSTALLATION ❑ REPAIR/ADDITION ❑ JDESTRUCTION (No septic,system permitted if public sewer is <br /> Installation will serve: Residence Commercial_ Other i �= available within 200 feet./ V <br /> Number of living units: Number of bedrooms i t <br /> Character of`soil to a dep of 3 feet: -f -f..}�, n }_; f <br /> SEPTIC TANK ( : Water table depth <br /> Type/Mfg Capacity — , No.,Compartments <br /> PKG. TREATMENT PLT. EJI <br /> Method of Disposal <br /> Distance to nearest: Well Foundation - Property Line <br /> — <br /> LEACHING LINE El -No. & Length of lines Total length/size ' <br /> FILTER BED ❑ Distance to,nearest: WellFoundation i I <br /> Property Line <br /> SEEPAGE PITS ❑ , Depth Size Number <br /> SUMPS ❑ Distance to dearest: Well Foundation E. ° ]]] <br /> Property Line <br /> DISPOSAL PONDS ED ,. I <br /> it r <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. r , <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-thy work fog whiich this permii is issue`d'I shall em loy persons subject to workman's compensa- <br /> tions._ <br /> tion laws of California." p 1 <br /> The applicant ust H for all req ed in C' lete'cdrawi69 do reverse side. <br /> Signed <br /> Title Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by �7zl <br /> Date -� Area C/ <br /> Pit or Grout Inspection by Date Final Inspection by �J <br /> Date a <br /> Additional Comments: - <br /> ❑ Stk 466-6781 ❑ Lodi 369-36211. ❑ Manteca 823-7104 ❑ Tra 83Fr6385 0 T <br /> Applicant Return all copies to: Environmntal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,'Stk., CA 95201 //l�� :G AJC 1 f <br /> FEE AMOUNT UE . AMOUNT REMITTEpCK f <br /> INFO CASH RECEIVED BY DATE PERMIT`NO. <br /> + EN 18-241REV.1/s5) C 0 <br /> EN 1426 <br />