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11 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r' 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> a <br /> (Complete in Triplicate) <br /> 4 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 /> {I 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 I1! <br /> Local Health District. <br /> t A Job Address <br /> / City <br /> ('-a 64 Lot Size PM <br /> ^ F Owner's Name 1 Ki W 10'jam' _ AddressPhone <br /> fl- 2 72- II <br /> Contractor G� Address +� Z( L 7 <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WEI, WELL REPLACEMENT DESTRUCTION ❑ <br /> I <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHp ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 7� SEWER LINESI <br /> DISPOSAL FLD. 72�' PROP, LINE f <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL P BLEM AREA CONSTRUCTION SPECIFICATIONS r/ *1'� <br /> ❑ Industrial ❑ Open Bottom Manteca Dia, of Well ExcavatiDia. of Well Casinomestic/Private �' ravel Pack ❑ Tracy Type of Casingcev SPec�Catl9ns❑ Public O Other ❑ Delta Depth of Grout Seal l�/� Tf ❑ Irrigation _� YPe of Grout <br /> t --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Dane ❑ Type of Pump H p <br /> State Work Done C <br /> IE Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> a !['TYPEI OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is h <br /> Installation will serve; Residence— Commercial— Other available within 200 feet.) <br /> F�, Number of living units: Number of bedrooms <br /> _• <br /> Character of soil to a depth of 3 feet: Water table depth i <br /> ;SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG.TREATMENT PLT. E-1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line t <br /> 0 !LEACHING LINE ❑ No. & Length of lines l <br /> Total length/size <br /> I FILTER BED ❑ Distance to nearest. Well ! <br /> Foundation Property Line <br /> Ii <br /> r� ��SEEPAGE PITS ❑ Depth Size <br /> Number II k <br /> ! ISUMPS ❑ Distance to nearest: Well Foundation Property Line i f <br /> i DISPOSAL PONDS ❑ <br /> :,I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinancesstate lawd Y <br /> I;rules and regulations of the San Joaquin Local Health District. I <br /> , s, an <br /> 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." <br /> certifies the following:"I certify that in the performance of the work for which this Contractor's hiring c sub contracting signature <br /> � permit is issued <br /> ltion laws of California." , I shall employ persons subject to workman's compensa- <br /> The applicant mu a or all re ire m, ctions. Complete drawing on re <br /> ver e. <br /> jSigned UZ Title: V <br /> Date: <br /> R DEPART ENT USE ONLY <br /> _} Application Accepted b]5±y �] �j <br /> Date Area `-' " 1i <br /> Pit or Grout Inspectin Final Inspection by_ / „_ Date F <br /> '` <br /> Additional Comment [f r 1 rStk, 466-6781 ❑ Lodi ❑ Manteca 823-7104 El Track83x6385 Q r C/t(/ <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. o Stk., C 95201 ' <br /> VV I <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y <br /> INFO CASH DATE PERMIT`�NO. <br /> 4 <br /> + EH W24(REY,i i e 5} <br /> F <br /> EN 14-29 <br />