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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (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 <br /> Local Health District. /� ,(ft, S <br /> ( <br /> Job Address _ ROW�t/ � ._ City Lot Size j • � 13C-- PM- <br /> Owner's <br /> 3C► PMOwner's Name <br /> M /. V i" 13E n S �ddress 4 Phone 9 3 5_` <br /> Contrartor ,E r Address License No. Phone -- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS <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 ❑ 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 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIOfV REPAIR/ADDITION ❑ DESTRUCTION ❑ jNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_X Other <br /> Number of living units: Number 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. ❑ Method of Disposal <br /> /G �i� <br /> Distance to nearest: Well��i� Foundation Property Line SO <br /> LEACHING LINE No. & Length of lines L 1 n/ Ufa Total length/size <br /> FILTER BED ❑ Distance to nearest: Foundation /�_ Property tine <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ 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 /> 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 /> 7 <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ parsons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m s call for II required ' ns. Complete drawingo ers si ./,�7 <br /> Signed Title: -� 1Q Date: <br /> /A /' FOR DEP MENT USE ONLY <br /> Application Accepted by v— Date f Area 07 <br /> Pit or Grout Inspection by Date Final Inspection byDate <br /> � l �o Sr,sfnlLafr was �sa��h! cvc 7� �n accco dp.s�� �– <br /> Additional Com a s: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy 835- <br /> Applicant- Return all copies to: Environmental Health Permit Services 1601 azelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT <br /> INFO �1 CASH 1G lld1��/ <br /> + EH 13-241REV.1/e 5) ��., b0 ,c.1�� �� <br /> EH 14-26 <br />