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s <br /> APPLICATION FOR PERMIT <br /> bAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephorle {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 /> APP <br /> Job Address City Lot Size PM <br /> Owner's Name _-_. FI'/4!�reC� og : -- _ Address' T s Phone. <br /> I ContractorAddress__?—y. M�4 License No.2, ` Phone / <br /> TYPE OF WELT,/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 /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial . .w ❑ Open Bottom ❑ Manteca 'Dia. of Well Excavation Dia. of Well Casing <br /> wC Domestic/Private C! Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Public fl Other n Delta Depth of Grout Seal . Type of Grout <br /> I Irrigation =Approxi Depth I d Eastern Surface Seal Installed by _ <br /> i <br /> Repair Work Done ❑ Type of Pump H,P. State Work Done <br /> ell Destruction ❑ Well Diameter Sealing Majerial Itop 501 <br /> r - -Depth Filler Material I13elow.501f <br /> T PE OF SEPTIC WORK: NEW INSTALLATION IJ Rr PAIR/A DDITION;K DESTRUCTION 11 INa septic system permitted if public sewer is ILA <br /> available within 200 feet.) <br /> Installation will verve:- Residence_ .CommercialOther <br /> Number of living units _ . Number of bedrooms <br /> Character of soil•to a depth of 3 feet: $A —Ape 1367Water table depth <br /> SEPTIC TANK I ❑ Type/Mfg Capacity No. Compartments <br /> j PKG. TREATMENT PLT. El- ' Method of Disposal <br /> 11, , Distance`to nearest: Well Foundation Property Line <br /> 1 ! i <br /> €';LE.ACHING LINE ❑ No:'& Length.of-.46s' .9: d Total length ie <br /> J 'DiFoundation �� Property Line >6Fl TER BED stance torkeresi: Well� <br /> SE EPAGE PITS I I ':bepthi Size <br /> Number <br /> r <br /> S MPS L1 Distancj to nearest:.. Vtilell Foundation - Property Line <br /> ( 'DI, POSAL PONDS: ❑ <br /> I t ereby certify-.thai 1 have prepared tills application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> ' ru s and regulations of the San Joaquin Local Health,'I7istrict. <br /> H me owner or licensejd agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> en ploy any person in such mariner as to become subject to workman's compensation la4,of California."Contractors hiring or sub-contracting signature <br /> ce ifies the following: 1 certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> ti laws of California. <br /> T a applicant must call ori required inspections: Complete drawing on reverse side. I <br /> Si nod X Title: ! <br /> 7777 Date: <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area / <br /> Pit.or Grout Inspection by I Date Final Inspection by Date <br /> Additional Comments: 4 �, Ve d /J t <br /> ❑�Stk 466-67$1 ❑ Lodi 369-3621 Q❑ Mariteta 823-7104 El racy 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 CK <br /> i INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY <br /> ,PATE PERMIT'NO. ' <br /> 21 <br /> t-EH'13-24(RSV.11 x 51 �?__ + ,� �--y <br /> EH 14-26 -_'tt"a_ ! d �s' _ 0 i. i <br />