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- �, }-c <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN,LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,,STOCKTON, CA <br /> Telephone (209) 466.6781 <br /> F: <br /> PERMIT EXPIRES'IYEAR 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 /> Job Address C / //Q Lr/A Ti /J Ste,✓ <br /> r9 Cid Lot Size S'O X t d o PM <br /> Owner's Name /� 7� FE2,eE�� Address � Phone 57V34751e, <br /> Contractor Address 60-C AJ, G/LI-14A1 .60`15� License No. �yrY719 Phone -39 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> -PUMP- STALLATIOWE! . SYSTEM -# OTHER ❑ ! <br /> DISTANCE TO NEAREST: SEPTIC K SEWER LINES DISPOSAL FLD. PROP. LINE \ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROB EA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca 1 II Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 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 50'}, <br /> Depth Filler Material Welow:50') ° t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ ' REPAIR/ADDITION ❑ DESTRUCTION_. (No septic system permitted if public sewer,is I <br /> available within_2. )0-feetJ <br /> Installation will serve: Residence Commercial_ Other `r ` <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:. f' Water table depth <br /> SEPTIC TANK ❑ Type/Mfg ^t Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑. �i �'' <br /> s Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r I <br /> r <br /> 4 <br /> LEACHING LINE 0,]'.No.,&_Length of lines Total length/size <br /> FILTER BED ❑')Distance to nearest: r Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth 1 -SizeF + Number <br /> SUMPS ❑ Distance to nearest: Well } Foundation :;Property Line <br /> DISPOSAL PONDS ❑ <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. I <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 the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laves of California." <br /> The applicant must call for all required inspectio s. Complete drawing on reverse side. ' <br /> Signed Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date =_,E2_ Are. 2` <br /> Pit or Grout Inspection by Date Final Inspection by C1e W�� Date <br /> Additional Comments: /'S' ._ _ - <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 : ❑ Man 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE <br /> I� <br /> INFO AMOUNT D�U�E1 AMOUNT REMITTED DASH RECEIVED BY DATE PERMIT'NO. i <br /> + EH 13-24 IAEV.1/851 <br /> EH 14.28 � � • V/ l/� <br />