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APPLICATION FOR PERMIT <br /> }F a <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 /> 1 ' (Complete in Triplicate) - J, <br /> f 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 /> �w <br /> Job Address �T /5/0 6� w City N Lot Size �� x ZC)o PM <br /> { Owner's NameIR4, 6. YY[krl.•T',1Jr 'ZAddress ���l�I¢/Z q�6 Q�(P <br /> # Phone <br /> Contractor Address License No, Phone <br /> TYPE.-OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> ,FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE ``TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> t <br /> L-1 Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications <br /> ElPublic El Other f;. ❑ Delta Depth of Grout Seal Type of Grout <br /> j ❑ Irrigation �4pprox. Depth` ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done 1 p <br /> Well Destruction ❑ Well Diameter A`,R.Seafing Material (top 50') rV� <br /> Depth Filler Material (Below 50'1 U <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION❑ DESTRUCTION NINO septic system permitted if public sewer is LA <br /> ..; aZailable within 200 feet.) <br /> f Installation will serve: Residence Commercial_ Other <br /> I Number of living units: Number of bedrooms <br /> 1 Character of soil to a depth of,3#eet:-- r <br /> I p Water table depth <br /> iSEPTIC TANK ZTypelMf9' Capacity. No. Compartments <br /> PKG. TREATMENT� PLT. ❑ '• +r—_ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: WellFoundati— Property Line <br /> SEEPAGE PITS ❑ Depth ° Size <br /> Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 <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 laws, and <br /> rules and regulations of the San Joaquin Local Health District. <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."Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in theperformance <br /> 9 fY of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." -P <br /> The applicant mu II for all required inspections. Complete drawing on reverse side. Q. <br /> h Signed Title: 3 ^e'C7---p <br /> • �Data: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 3�� Area <br /> Pit or Grout Inspection by Datey Final Inspection by pie <br /> Additional Comment; <br /> ❑ Stk 466-6781 ❑ Lo 369-3621 ❑ Manteca 823-7 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 /> r <br /> FEE <br /> 1 <br /> INFO AMOUNT DUE ' AMOUNT REMITTED CK CASH RECEIVED 8Y DATE PERMIT'NO. <br /> + EH13-24(REV. /a r) <br /> £H 14-28 -7 - <br /> r I <br />