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APPLICATION FOR PERMIT .. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA �c <br /> Telephone {209} 466.6781 L� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) r`o � X� ] <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. 1562 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. 1 <br /> Job Address �� f0 nt C.i L City Lot Size x 7 . PM <br /> Owner's Name :TeN( IC'A �'CAvnlb Address Vk Phone 9 <br /> .4 <br /> �i <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �- <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Llf OTHER ❑ � <br /> 1. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWERf LINES DISPOSAL FLD. PRO <br /> ""-FOUNDATION AGRICULTURE WELL OTHE PITS/SUMPS <br /> INTENDED USE _TYPE OF WELL PROBLEM AREA CO ON SPECIFICATIONS � <br /> ❑ Industrial—,_ ❑ Open Bottom ❑ Mante Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private Cl Gravel Pack racy Type of Casing 4 Specifications { <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout i <br /> ❑ Irrigation `' pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Don Type of Pump H.P. State Work Done <br /> Well Des ion ❑ Well Diameter Sealing Material atop 501. t <br /> Depth Filler Material (Below-501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth 1 <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well-'-- Founeation z,- � ' 'Property Line <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 j :Number <br /> SUMPS ❑ Distance to nearest: Well Foundation '"^-" Property Line <br /> DISPOSAL PONDS ❑ } <br /> 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 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." <br /> The lica ust call for II requirfd inspections. Complete drawing on reverse side. ( 15-11 <br /> � <br /> Signed r Title: `c 'L` - t-,c�-"ter' Date: v U� 4 <br /> FOR DEPARTMENT USE ONLY <br /> �t`l14by <br /> D�.. <br /> Application Accepted by � <br /> DArea o� <br /> Pit or Grout fnspectio Date Final InspectionDat. I <br /> Additional Comments: � ' <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ MaNt6 823-7104 ❑ Tracy 85 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,CA 95201 <br /> FEE INFO MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE <br /> .7/e51 �� •vim ' 3spo Vit CPERMIT''N0. <br /> + EH 3-24(RSV <br /> 29EH1JOS e 1-1343 <br />