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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT " <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> -Telephone (209) 466'6781 <br /> PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED <br /> (C6Mp1ete'in Triplicate) vk r.N <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 Ryles and Regulations of the San Joaquin <br /> Local Health District. Y r;u y w . . .f myt-- a _e <br /> _AJab'Address-j � _.�1': LLd '', ee 64 rte'",ut Lot Size PM <br /> Owner's Name Address - V. -J Phone - - <br /> Contracto !'s 1 Address) LL 7k i/{ / License No::�'X.28rdOO Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> _ I <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 Hk PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottomi-0-Manteca,. ,Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ° Type of CasingJ" Specifications <br /> ❑ Public '17Other O Delta Depth of Grout Seal Type 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 (top-50') <br /> Depth aU r Material (Below 50') <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_..i Other _4 <br /> Number of living units: <br /> Numberof be rooms <br /> Character of soil to a depth of 3 feet: Wafer table depth <br /> r <br /> SEPTIC TANK ❑ Type/Mfg Capacity No.,Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation 3 Property Line <br /> Y <br /> LEACHING LINE U51'No. & Length of lines y Q Total length/size ` <br /> FILTER BED ❑ Distance to nearest: Well Foundation y[ PPoperty Line� S <br /> SEEPAGE PITS ❑ Depth + --Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation• Property Line <br /> i .. <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that'] have prepared this application and that the workwill be'done in accordance with'San Joaquin county ordinances, state laws, an _ <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 <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." - n---- — - -• - --- y�* _ <br /> The applican uat call for req 'red inspections. Complete drawing on reversesid <br /> Signed Title: l/-_[_- Date: <br /> FOR DEP4KMENT US NLY <br /> y <br /> Application Accepted by Date �� 5 Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ 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 REMITTEDCK RECEIVED BY DATE. PERMIT NO. <br /> INFO " CASH <br /> t EH18-24MEv.1/851 - a <br /> EH 1426 ti ©� <br />