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r - <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL TQN AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 'I'YEAR FROM DATE ISSUED <br /> . ., (Complete in Uplica#e)' 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 /> Job Address `7 `- <br /> City Lot Size PM <br /> Owner's Name AddressPhone <br /> - - �3Jr 7�J 6 <br /> Contractor � Address 3�� �` � �� License No. 3`a�`3e Phone �S=Z6/ : <br /> 4 TYPE OF WELT./PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> t <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE SEWER_LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION A RE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CQNSTR SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavatio Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public El Other ❑ Delta Depth of Grout Seal of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material{lop 50,)-- - <br /> Depthy Filler Material (Below 501 <br /> f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑^REPAIR/ADDITION DESTRUCTION ❑ {No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial 'Other <br /> Number of,livin units:, j ` <br /> g $Nurriber�of be {� ! <br /> Character of'soil to a depth of 3 feet: /1, Wate table depth <br /> £ � C�.rrCfZf <br /> SEPTIC TANK )e Type/Mfg C Capacity No.No. Compartments 2- <br /> PKG. TREATMENT PLT. ❑ .v Method of Disposal <br /> Distance to nearest: Well�'..— Foundation Z Property Line <br /> LEACHING LINE* ❑ No. & Length of lines Total~lengfh/size <br /> FILTER BE ElDistance to nearest: Well Foundation - Property Line <br /> i <br /> SEEPAGE PITS s ❑ 'Depth SizeNum6ei t <br /> SUMPS k CI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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. <br /> Home owner'br 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 applicant must II or all requir spa . s. Complete drawing on reverse side. <br /> Signed Title: <br /> Date: <br /> • �A- �FOR DEPARTMENT USE ONLY <br /> Application Accepted b �" r , <br /> Y Date t7�V�, ' Area Or'� <br /> Pitor Grout Ir�spectk by Date ! Final Inspection by Awa pats 31 ��� <br /> 1 3/fy��f� <br /> /00 <br /> Additional Com ants: <br /> 1 D Stk 466-6781 CJ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835- M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.- Box 2009, Stk., CA 95201 <br /> FEE <br /> i <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. <br /> +"EH 13-2¢{REV.1/13 s) to ' �) / Q� <br /> EH 10.28 �© y � 'f (0"'s-V7 <br />