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f <br /> i <br /> A APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) <br /> PERMIT EXPIRES.1=YEAR.FROM DATE ISSUED <br /> I (Complete in Triplicate) <br /> I 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 /> I <br /> -Local Health District. <br /> n /� <br /> Job Address 2 � �. 2912 e2 _ City 5 2'mG k%d/Lot Size PM <br /> I <br /> Owner's Name 12 ZMa.9 L4ZZPf d�_C Address S-5- .22 i:2� Z _ Phone e- <br /> Contractor Address License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEARE . EPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUN AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL P REA CONST ATIONS <br /> ❑ industrial ❑ Open Bottom ❑ Well Excavation Dia. of Well Casing <br /> ❑ Domestic)Private 01 Gravel Pa ❑ Tracy Type of Casing Specifications <br /> M Public 1l er 1-1 Delta Depth of Grout Seal Type of Grout <br /> -- <br /> a .I i Irrigation <br /> —.-Approx. Depth i I Eastern Surface Seal Installed by <br /> I - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Donel_ <br /> Well Destruction ❑ Well Diameter Sealing Material (tap 50'1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK:" NEW INSTALLATION 1.1 RE/PAIR/ADDITION I I DESTRUCTION4 o septic`,system permitted if public sewer,is- vi <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 <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> j PKG. TREATMENT PLT; 0 *.4 Method of Disposal ({� <br /> [I Distance to nearest: Well Foundation Property Line k i <br /> f <br /> I _ <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property Line <br /> r _ <br /> f / SEEPAGE PITS I I Depth Size T} 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 /> i rules and regulations of the San Joaquin Local Health Diltrict. <br /> 6 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 applicant mult call for all required inspections. Complete drawing on reverse side. / <br /> Signed X ZltTitle: tib(/ e Date: <br /> FOR DEPARTMENT USE ONLY r <br /> fApplication Accepted by Date,_ <br /> Pit or Grout Ins !� <br /> paction by Date Final Inspection by Date; <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> kApplicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUEAMOUNT REMITTED <br /> INFO RECEIVED BY DATE PERMIT'NO. <br /> r EH 1 -24(pEV.i/tt5) --- � ��� � <br /> EH 14-2e +.a.� l <br />