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4 APPLICATION FOR PERMIT J <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA L <br /> Telephone (209) 466-6781 ✓r2�. �tr7 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> s� 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 /> _ y -, Lot size s- <br /> Job Address City���� PM # <br /> Owner's Name I< Address ��.2 S F �dp l�u c�+�' Phone 06 y o 8 ve i <br /> 4 <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ e <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LI <br /> FOUNDATION AGRICULTURE WELL OTHER WELL TS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIO ATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca ell Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tr Type of Casing Specifications <br /> ❑ Public ❑ Other j ❑-Delta Depth of'Grout Seal Type of Grout <br /> ❑ Irrigation pprax. Depth ❑ Eastern Surface Seal Installed by- <br /> Repair Work D Type of Pump H.P. State Work Done <br /> Well D ction ❑ Well Diameter Sealing Material (top 501 <br /> Depth 1 Filler Material {Below 501 <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 A Commercial_ Other <br /> Number of living units:- Number of bedrooms; <br /> Character of soil to a depth of 3 feet R Water table depth <br /> SEPTIC TANK `,❑ Type/Mfg, Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑...y, r Method of Disposal <br /> Distance to nearest: Well Foundation ° Pro Line <br /> Property <br /> • 't I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ .1 ; <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 District. <br /> Home owner or licensed agent's sighatu're 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 applicantt..m�ust call for all required inspections. Complete drawing on reverse side. <br /> Signed X_!f7_-.__mac �{ Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by f - Date - Area / <br /> I '] <br /> Pit or Grout Inspectio y Date Final Inspection by Date <br /> Additional Comments: f S <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 /> /NFO <br /> FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT''NO. <br /> + EH 13-241REV.$/as) 13.�. db �� �U[:� *�•� ­7 ->0 <br /> EH 1428 1 <br />