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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,,STOCKTON, CA <br /> 'Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> b,,:,. . ,..,� , (Complete in Triplicate) t±1 c,, , t <br /> Application is hereby made to the San Jbaquin Local Health District for a permit to construct and/or install the work herein described.'This application is <br /> r. made in compliance with San Joaquin County Ordinance,No:549 for sewage or No. 1862 for well/pump and the Rules andRegulations of the San Joaquin <br /> Local Health District. to <br /> /y rn <br /> Job Address-' <br /> 5 W ISS 4+1 I'S G-t-Z�r:l S��tbn1 1 i . 'E8 , <br /> city <br /> ` { Lot Size PM <br /> Owner's Name �� (��w r " Address t Phone <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 5 ER LINES SPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRI LTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ARE TRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of-Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private 0 Gravel Pack ❑ Trac pe of Casing Specifications <br /> ❑ Public C1 Other ❑ to De th of Grout Seal Type of Grout <br /> El _-._Approx. Depth Eastern Surface Seal Installed by <br /> Repair Work Done ❑, Type of Pump H.P. State Work Done <br /> Well Destruction ❑' Well 17iamet ` Sea g Material (top 50'j <br /> ,r Depth <br /> I Filler Maferial (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO ❑'(No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Comm r ' <br /> e clal, Qther <br /> - <br /> Number of living units: V- <br /> Numb'ef of bedrooms <br /> Character of soil to a depth of 3 feet: s -Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ r Method of Disposal <br /> Distance to nearest: Weil Foundation Property Line <br /> r _ <br /> LEACHING LINE ❑ No- & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth 'I Size Number i <br /> SUMPS ❑ Distance to nearest: ` Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> i <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." Contractor's hiring or sub-contracting signature 1 <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 applic ust ca r allyequired inspections. Complete drawing on reverse side. <br /> �Cv/( 1 <br /> Signed Title: <br /> ! � Date: <br /> - FOR DEPART ENT USE ONLY �J ° <br /> Application Accepted by t Date <br /> Pit or Grout inspection by } Date Final inspection by pie <br /> Additional Comments: ! r <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 p 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 REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> i <br /> '+ EH 13-24IREV,1/951 d T' <br /> EH 1428 ��* <br /> I <br />