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APPLICATION FOR PERMIT it <br /> i SAN JOAQUIN LOCAL HEALTH DISTRICT 1, <br /> 1601 E. HAZEL i ON AVE' ., STOCKTON, CA <br /> Telephone (209) 466-67$1 <br /> I PERMIT EXPIRES -1 YEAR 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 Ryles•and Regulations of the San Joaquin 1 <br /> Local Health District. <br /> E s, <br /> Job Address � �/ } ' ��� ��n�� ` Ci Lot Size .r PM <br /> F .• , ,. 4 .. `�� <br /> k' Owner's Nam / Address 7 vi V� - Phone'C" <br /> Contract _ e ��'-^' ddress .1_47e.1_6 �77� --____License No. 7� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ : <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ElDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ` <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other i ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---4pprox}Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work-Done r <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth I Filler Material IBelow 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic-syst0n'perrnitted if public sewer is i <br /> ' available within 200 feet.) ) <br /> Installation will serve: Residence_ ^_� Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> k Character of soil to a depth of 3 feet Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ —! • Method of Disposal <br /> j Distance to nearest: Well Foundation Property Line <br /> I s <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to neatest:.,,,,Well Foundation Property Line 1 <br /> SEEPAGE PITS ❑ Depth °( Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I. <br /> hereby certify that I have prepared this application aha—tKaf 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."Contractors 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." A <br /> 'The appli6ant must call for all required inspections: Complete drawing-on reverse side <br /> Signed <br /> e '� Title:. � - =�- - -Date:-7r-� <br /> t <br /> f FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 7 `�//� Area <br /> Pit or Grout Inspection by Date Final Inspection by 4 - 9 k A4%d�« Date —a 3'$�`• <br /> Additional Comments: <br /> Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> plicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IFEE NFO AMOUNT DUE' AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT'NO. <br /> + EH 1&24(REV.t/35) � <br /> EH 14 4 <br /> 28 Q� J <br />