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s - APPLICATION FOR PERMIT <br /> F SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1YEAR 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 District. <br /> l <br /> r j�F T41� RT�'.si SIO C "O-le p r <br /> Jab Address �� <br /> //? <br /> r +Cit//y� Lot Size-��X��PM <br /> Owner's Name'> /ta/Y j 1S/.s' yl�r/`',quern S' Address P5f f 7�' r r/bgg Phone ^� <br /> Contractor �� Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER LJ <br /> DISTANCE TON • EPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUND AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM NSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of We tion Dia. of Well Casing <br /> Pack <br /> r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> l M Public F1 Other F�. I1 Delta Depth of Grout Seal Type of Grout {J� <br /> I I Irrigalion _..Approx. Depth I I Eastern Surface Seal Installed by o_i <br /> Repair Work Done-� ❑ Type of Pump H.P. State Work Done <br /> Well Destruction O r Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l-1, DESTRUC-TION o septic system permitted if public sewer is <br /> available within 200 feet.) <br /> f installation will serve: Residence F Commercial= ,Other <br /> Number of living units: Numbe of bedrooms <br /> Character of soil to a depth of 3=feet Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ilMethod of Disposal <br /> . ,- <br /> s : Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> il <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br />( �1w <br /> SEEPAGE PITS I I Depth 'I Size Number- <br /> SUMPS <br /> umberSUMPS ❑ Distance,*to nearest: Well Foundation Property Line <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 /> I rules and regulations of the San Joaquin Local Health District. <br /> j Home owner or licensed agent's signature certifies the following: "f certify that in the performance of the-work for which this permit is issued, 1 shall not <br /> E 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 call for all, wired inspections. Complete drawing on reverse side. <br /> }t <br /> Signed Title: A? � <br /> Date: <br /> FOR EPARTMENT USE ONLY <br /> Application Accepted by l Date! / Area Q <br /> Pit or Grout Inspection by 1 Date [ )) Final Inspection by Date <br /> Additional Comments: ! / Tt� L1// <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mante 823-7104 ❑ fracy 8355-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> f <br /> INFO FEE AMOUNT DUE r AMOUNT REMETTEt7 CASH RECEIVED BY DATE PERM17'NO. <br /> + EH 13-24{REV.r/ms) r/ �7 <br /> EH t4-26 - <br />