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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 /> E. (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 comply ce with San Jnaouin County Ordinance No.549 for sewage or No. 1662 for.well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health fDistrict.� / _ <br /> �J Z 3 <br /> Job Address �Lr �L[lt��P11 �". City Lot Size PM <br /> a <br /> Owner's Name/ ! /�"`- 10_0� Address�V,/2 c I/r AGr�1.?:i" '`-(_• Phone : J <br /> Contract Address (License No. Zz - Phone �1/0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> �FOUNDATIO.N.. _AGRICULTURE WELL,-. - OTHER WELL --- - PITS/SUMPS— - <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 <br /> ❑ Industrial ❑ Open Bottom ❑Manteca 4' Dia:,of-Well.Excavation Dia. of Well Casing ; <br /> y._.,._..❑-Domestic/.P_rivate.r --❑-Gravel-Pack --[DTracy. --Type-of-easing------ --- ­-Specifications- ­ <br /> L1 <br /> "Y--Specifications- �°� - <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal i Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50'1 I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is 6 <br /> j available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Cher <br /> Number of living units Number of b rooms <br /> l <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 1 Capacity - 1 No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 12"No. &.Length.of lines Q Total length/size Q X <br /> FILTER BED ❑ Distance'tto nearest: Well Foundation 140 ` Property Line <br /> SEEPAGE PITS El Depth-===:"�—�Size­- — - Number <br /> SUMPS _C[Jr�Distance to nearest: Well f Foundation Property Line t <br /> DISPOSAL-PONDS El -+ <br /> I <br /> ,4 Ihereby 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 /> ,f 1. 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 f <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 /> x rTheapplicant. ust call forMalluired inspections. Complete drawing on reverse ide. <br /> Signed X Title: Date: i <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date_�LZ <br /> i <br /> Additional Comments: j <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104ElTracy 8355-6385 <br /> Applicant- Return all copies to. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> C ilk <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMtT'NO. <br /> r EH13.241REv.t/a51 <br /> EH 14-26 - of <br />