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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6791 <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 /> mads in compliance with San Joaquin County Ordinance No.549 for sewage ar No,1862 for well/pump and the Rules and Regulations Df the San Joaquin <br /> Local Health District. <br /> Job Address7 <br /> City0 � Lot Size 7 f� PM <br /> fi - <br /> Owner's Name _ <br /> Address -..—��Zt?-------�. Phana <br /> Contractor_ �.Add—, 50�CfZR�+?v.,Ta CA, <br /> TYPE OF WELL/PUMP: License No, --Phon1�� <br /> NEW WELL El WELL REPLACEMENT CJ DESTRUCTION C] <br /> PUMP INSTALLATION Li SYSTEM REPAIR C1 OTHERS <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES <br /> — DISPOSAL FLD. PROP.LINE <br /> FOUNDATION AGRICULTURE WELL . _ OTHER WELL <br /> PITSISUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECtFICATIO S_ — <br /> ' Balton IJ Mantaca Dia,of WJe1l Excavation <br /> [J DomesticlPrivateel Pack ❑Tracy Type of Casio � taNeft Cast g �— <br /> L� g--- --- Specifications <br /> Public ❑Other <br /> D Delta Depth of Grout Seal <br /> L7 Irrigation <br /> ---A <br /> El CI Eastern Surface Seal Installed by Type of Grout_.,.__. <br /> Repair Work Done Ci Type of Pump H.P. <br /> Well Destruction State W rk Done <br /> Well Qiameter Sealing fNalerial liep4 <br /> 8y y <br /> Depth Filler Material{Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L7 REPAIR/AOD1tfON LJ DEST CTION fa INo septic system permitted if public sewer is <br /> Other <br /> Installation will serve: Residence_ Commercial_ available within 200 feet., <br /> Number of living units:— Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK dWater table depth <br /> Type/Mfg <br /> PKG.TREATMENT PLT.[ICapacity No.Compartments <br /> Distance to nearest: Well Foundation Method of Disposal <br /> Propeny Line <br /> LEACHING LINE ❑ No.&Length of fines <br /> FILTER BED Total length/sire <br /> L7 Distance to nearest: Well_ Foundation <br /> Property Lino <br /> SEEPAGE PITS 0 Depth _ Size_ <br /> SUMPS17-1 Number <br /> Distance to nearest: Well Foundation <br /> DISPOSAL PONDS 0 Property Line <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state lawsand <br /> rules and regulations of the San Joaquin Local Health District. , <br /> Home owner ar 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 laws of California." <br /> The spplicant m calf for all required inspections.Complete drawing on reverse side. <br /> Signed <br /> Date: <br /> F R P ENT USE ONLY <br /> Application Accepted b � <br /> Data -� Area <br /> Pit or Grout inspectbn y Date- Final Inspection by )]ate <br /> -----Additional Comments,Camwntsc <br /> — — .. _ <br /> Or <br /> 13 Stk 466-6781 0 Lodi 369.3621 0 Manteca 823.7104 0 Tr y 83L+6385�/r5 <br /> APPlicant-Return all copies to:Environmental Health Permit/Services 1601 E.Hazellon Ave.,P.O. Box 2009, <br /> r <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO RECEIVED BY DATE PERMIT'N0. <br /> 1 V3Ve.6 �b-'s-q <br /> r <br />