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r <br /> _ APPLICATION FOR PERMIT <br /> } SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone {209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> I (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 Distfict. <br /> Job Address —_ � /��/V�j�e!� 't City 1!! ® Lot Size v Ala PM <br /> qyOwner's Name 2W H± xXddress &_.3�0 /1r/✓phone <br /> 4'» <br /> Contractor S ddres's I� } N1'&?/l .dam_License No. 6 Phone .ems <br /> TYPE OF WELL/PUMP: NEIN WELL) -WELL-REPLACEMENT ❑ �'-DESTRUCTION ❑ — 1` <br /> P � ,„PUMP fNSTALLATION " / SYSTEM-REPAIR-L] OTHER-i"'��--+ �;f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD..--- i. PROP. LINE <br /> FOUNDATION � AGRICULTURE WELL OTHER WELL- PITS/SUMPS <br /> INTENDED USE :TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Z Dia. of Well Casing r <br /> I �Domestic/Private Gravel Pack ❑ Trac T .��� <br /> A 1 y Type of Casing � Specifications Domestic/ J <br /> I I Irrigation M Public f 3 Other Cl Delta Depth of Grout Seal `�� � Type of Grout <br /> I A & � - , r <br /> g' T_ pprox. Depth I 1 Eastern \Surface'Seal'installed by <br /> Repair Work Done 0 Type of Pump H.P.!. Work Done <br /> Well Destruction ❑ Well Diameter Sealing Mater&5(top-50')_ <br /> ` Depth ' Filler Material (gelow 50') ­' .__f-' r OQ <br /> `r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIR/ADDITION l I;'-DESTRUCTION l I ;(No septic;system permitted if public sewer is <br /> +�j i j "^"' vatr ble within 200 feet,0 <br /> Installation will serve: Residence_ Commercial_ Other <br /> t <br /> Number of living units: �_ ,.FNumber_of_bedrooms <br /> Character of soil to a depth of 3 feet: d � � Water table depth <br /> SEPTIC TANK ❑ 1 Type/Mfg' Capacity No. {{Corh'paitments <br /> PKG. TREATMENT PLT. ❑ y .�`� -�-MetAod of,Disposal; <br /> Distance to nearest: Well Foundation Property Line '. <br /> LEACHING LINE ("fh No. & Length of lines Total length/size k"t� <br />' FILTER BEDr yy ❑��, Distance}to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l 1 Depth I Size Number <I <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 4 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, k 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." i <br /> The app7�= <br /> St. qui ns. Complete drawing on reverse is h <br /> Signed Title: ° Date: 4 <br /> F. DEPARTMENT USE ONLY }( <br /> I <br /> Application Accepted by ' Date v Area i <br /> Pit or lou Inspection by DateFinal Inspection by \ Q Dat§ / �a <br /> k i <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O TracyM 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PERMI7'Np, <br /> i <br /> /r i <br /> +.EH13-24iREV.rinSr L 0 fA � 757 y <br /> EH 14-26 <br /> I <br />