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1 <br /> APPLICATION FOR PERMIT <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 /> (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 District. f <br /> t <br /> fG� '1 <br /> Job Address � City Lot Size PM <br /> Owner's Nam AA &MI&A2 Address CSQ d'' Phone r Fu <br /> I f _ <br /> si <br /> Contrac r Address � O w `License No. 2Z�Phone 0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION_❑ s <br /> 4 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Q OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C) Industrial ❑ Open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing <br /> t <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1-1 Public I� Other „- -__ _❑ Delta Depth of Grout Seal _ Type of Grout - _ <br /> 11 Irrigation ___Approx:Depth I'1 Eastern µSurface Seal Installed by - <br /> ,. O _-_- -- <br /> Repair Work Done Type of Pump H.P. <br /> _ r 'date Work Done <br /> L-1 _ <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 <br /> Depth j filler Material (Belo ) IA <br /> — <br /> TYPE'OF SEPTIC WORK:; NEW INSTALLATI EPAI ADDITION [,OT- DESTRUCTION 1-1 (No septic system perriiated if public sewer is <br /> F i available within 200 feet.) <br /> Installation will serve: Residence ' CommercialO ther <br /> { <br /> Number of living units: _L__ Number edroom — <br /> Character of soil to a depth of 3 feet: Water table depth �la +SEPTIC TANK _><1 `` <br /> Type/Mfg ' r y_X L Capacity - No. Compartments <br /> _ a <br /> PKG. TREATMENT PLT. ❑ t Method of Disposal <br /> Distance to nearest: Well oundation . Q--. Property Line <br /> i a <br /> i LEACHING LINE ❑ No. & Length of lines Total length/size ro <br /> FILTER BED ❑ Dis[a c6 to nearest, Well I Foundation Propy LineAN- <br /> `xz'JEEPAGE PITS I I Depth _ Sze-! ) / Number <br /> SUMPS Ll `Distance to-nearest."' Well r. Foundation Property Liho` ' <br /> DISPOSAL;PONDS: ❑ <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 Di `riot. �-M.F_ <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 <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- <br /> tion laws of California." y <br /> The applicant call for quir inspections. Complete drawing on reverse de <br /> 1 Signed X Title: Date 1 <br /> FOR DEPARTMENT USE-ONLY <br /> _1 _� a Zr <br /> Application Accepted b DatArea <br /> (� <br /> Pit or Grout Inspection by Date Final Inspection byDated <br /> Additional Comments: * d )L— A,sinz t _ <br /> ❑ Stk 486-6781 © Lodi 369-3621 ❑ 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 CASH \ RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> *,EH 13-241REV.ii»s) <br /> EH <br /> 14-26 <br /> 4�. <br /> t <br />