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N. <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON 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. <br /> This is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welt/pump and the Rules and Regulations of the Sanrcation Joaquin <br /> Local Health District., 7 1 <br /> Job Address ! 49 V r/ 1 <br /> r7 i <br /> City Lot Size pM + <br /> Owner's Namey L' <br /> i�L Address _ � / 0 7 1 /�c ,t�l���o Phone C� T <br /> Contractor ' <br /> Address License No. Phone <br /> TYPE OF LL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER ❑ <br /> S <br /> DISTANCE TO NEAREST: TANK SEWER LINES DISPOSAL FLD. P NE . / <br /> UN IV AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL sPRO13L -CONSTRUCTION SP TIONS <br /> ❑ Industrial '❑ Open Bott ❑ Manteca „ f W avation' Dia.'of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy, ,,,µ t eloCasn <br /> ❑ Public Specifications <br /> ❑ Other ❑ iDepth of Grout Seal I -t Type of Grout \ <br /> ED Irrigation -APww— prox-D ❑ Eastern Surface Seal Installed by <br /> Repair Work Done +❑'`T. um p H.P.- I ' State Work Done �V <br /> Well Destruction ❑^ Well Diameter �' `' 4 fi <br /> Sealing Materi ll,ftop 50'1 <br /> *y- Depth = Filler Material (Below 50'1 r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑p DESTRUCTION,*(NR septic system permitted if public sewer is <br /> Installation will serve: available within 200 feet.) <br /> Residence Commercial` Other �� <br /> Number of living units: Number of bedrooms r <br /> Character of soil to a depth of 3 feet: Water table depth ' <br /> SEPTIC TANK ❑ Type/Mfg � <br /> Catacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Pj Method of Disposal <br /> o <br /> Distance tnearest: Well+ "� " <br /> s �I Foundation �— -- Property Line i <br /> (*LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER"BED` El Distance to nearest: Well Foundation' Property Line <br /> SEEPAGE PITS ❑ Depth Size Number p <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 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. ""^' '`" —� err- <br /> Home owner or licensed agent's signature certifies the following: "1 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,_l'shall employ persons subject to workman's com nsa <br /> tion laws of California." -,__y; J pe ; <br /> The applicant must call for all required ins ctions. Complete drawing on reverse side.. <br /> t _ <br /> Signed Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY y <br /> Application Accepted by Date <br /> 2 Area <br /> Pit or Grout Inspecti y Date :Finalnspection by <br /> Dated _Q <br /> Additional Comments; <br /> ❑ Stk"466 6781 Lodi 369-3621` ❑ Manteca 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 95201 <br /> FEE AMOUNT DUE AMOUNT REMITT RECEIVED BY DATE PERMIT'NO. <br /> INFO /� AS <br /> + EH 13-24(REY.1/a s) �i 4r <br /> EH 14.26 <br />