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.. .. tin-..*- - �i'^nF'c+-•=r.,?rsa�R �- �Mm""*-.. S' r r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL*HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE.,.STOCKTON, CA <br /> Telephone (209) 4666781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .1 <br /> . .0 .. (Complete in Triplicate) . <br /> Application is heieby 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 /> '3. w,: K. <br /> Job Address vLIQ h City Lot Size PM <br /> Owner's Name 41W104, / A Klolf Address <br /> Phone �� <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> P INSTALLATION ❑ SYSTEM REPAIR ❑ OTH <br /> DISTANCE TO NEAREST: TIC TANK SEWER LINES FLD. PROP. LINE <br /> FOUND AGRICULTURE OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL P EA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom Manteca f Well,Excavation . Dia. of Well Casing <br /> ❑ Domestic/Private ❑ ack ❑ Tracy Type of Cast Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigati _�__4pprox`Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diametei Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Wo septic system permitted if public sewer is <br /> r;' i -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( CapacityNo. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE O No. & length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth _Size Number c <br /> SUMPS ❑ -Distance to nearest: -Well Foundation ,Property Line- * <br /> DISPOSAL PONDS ❑ . I <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 /> certifies the following: "I certify that in the performance of the work for.which this permit is issued, I shall employ p y persons subject to workman's compensa- <br /> tion taws of California." <br /> The applicant ust call o required inspections. Complete drawing on reverse side. // <br /> Signed X Title: 4 a Ow ,P Date: __1/1 <br /> EOR,DEPARTMENT USE ONLY <br /> Application.Accepted-1by <br /> Date` Area <br /> •� � / <br /> Pit or Grout Inspection DateFinal Inspection by DateAdditional Comments: / (i <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 8231104 ❑ Tracy 8355-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE ^� AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH1241RE5/.1/85) .. -Vt) '?'S--�O(� <br /> EH 14 <br /> -26 <br />