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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 /> (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 /> � f <br /> Jab Address � ! City V l Lot Size a 1 PM <br /> i <br /> _ r <br /> S <br /> Owner's Name �C�r ' "q �L�_- Address Phone <br /> Contractor Address 23 <br /> a License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ ; WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION EJrSYSTEM REPAIR ❑ OTHER ❑ , <br /> DISTANCE TON SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FO ON AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL EM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Specifications <br /> ❑ Public `-•- ^-' ❑ Other- -"` ' ' ❑Delta 'Depth of Grout Seal Type of Grout p� <br /> C1 Irrigation JApprox:'peptFi ❑ Eastern Surface Seal Installed by <br /> Repair Work Done .El 'Type of Pump H.P. State Work Done= <br /> I Well Destruction �❑ Well Diameter. . Sealing Material {top 50'1 h <br /> Depth Filler Material (Below 50'1 - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑, REPAIR/ADDITION ❑ DESTRUCTIONo septic system permitted if public sewer is <br /> k available within 200 feet.} <br /> Installation willlserve: Residence— Commercial_ Other e <br /> 4 Number of living units: Number of bedrooms , I IT <br /> Character of soil to a depth of 3 feet: t Water table depth <br /> SEPTIC TANK r ❑ Type/Mfg Capacity ; No. Compartments { <br /> PKG. TREATMENT PLT. ❑ 1 1 Method of Disposal <br /> Distance to nearest: Well Foundation .Property Line s 1 <br /> LEACHING LINE 1 ❑ No!& Length of Tines _ Total length/size <br /> FILTER BED I ❑ Distance to^nearest`," Well Foundation Property Line s <br /> SEEPAGE PITS ❑ Depth Size Number I <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I <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 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." Contractors hiring or sub-contracting signature <br /> ce 'ies the followi "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 la of California." i <br /> The applica t call r al req ! d i pections. Complete drawing on reverse side. <br /> 6� <br /> Signed Title: � d//CLl° JYl� Dater _/9!g7 <br /> FOR DE ARTMENT USE ONLY <br /> Application Accepted b �C! <br /> � pp p Y Date-,;3 <br /> e�y1 kZ Area O <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> r = Additional Comments: 0 7=)- <br /> ❑ Stk 466-6781 ❑ Lodi 369 ❑ Manteca 623-7104 ❑ 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 /> FEE✓✓'ff INFO AMOUNT DUE - AMOUNT REMITTED CK RECEIVED BY DATE PERMIT-NO. <br /> #' +EH13-Y41IREV.4/N57 r36 <br /> EH 14'6 0<_ of/Vo �/i� I11� ""� 3_�70 wQQ <br />