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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone !2091 466-6781 <br /> PERMIT EXPIRES TYEAR 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. 1B62 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> i <br /> Job Addres Cit , Lot Size a4fteA4gPM <br /> J r i <br /> Owner's`;Name` / a4? Address: �[f// r�� Ai i Phone <br /> Coriwc rorY / �� Address �Cl /�/ eA ,, License EV �Z-6 Phort <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION ❑ { <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> w FOUNDATION AGRICULTURE WELL -.OTHER WELL --,PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation pia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ' <br /> f <br /> M Public Cl Other I7.Delta Depth of Grout Seal Type of Grout _ <br /> i I Irrigation _.-Approx. Depth I I 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 50') <br /> Depth Iler Material IBelow 50') ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR ADDITION. DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) 'V <br /> Installation will serve: Residence—mCommercial Other / <br /> Number of living units: —/LNuber of be rooms �, 1 <br /> Character of soil'to a depth of 3 feet: Water table depth _ f I <br /> SEPTIC TANK ❑ Type/Mfg - Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ _ Method of Disposal <br /> Distance to nearest: Well Foundation ' Property Line <br /> LEACHING LINE No. & Length of line 7-ta1 length/size <br /> FILTER BED ❑ Distance to nearest: Well k-�V Foundation 10 Property Line - 1 <br /> I <br /> SEEPAGE PITS f I Depth Sire Number <br /> SUMPS � Distance to nearest: Well X Foundation_ Property Line <br /> —DISPOSAL-PONDS ❑ - = • - , <br /> I hereby certify that I have prepared this application and 1hat'the work will be done in accordance with San Joaquin county ordinances, state laws, and� 1 <br /> rules and regulations of the San Joaquin Local Health D stfict. <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, l 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 Ca fornia." <br /> The applicant t all for eq 'ed inspections. Comp`late-drawing-oni'rever e. <br /> Signed XTitle:, Date- <br /> FOR DEPARTMENT USE ONLY <br /> �j <br /> Application Ace ed by Date ` u Area <br /> Pit or Grout Inspection by Date Final Inspection by Y DateU <br /> Additional Comments: <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 95201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24 IREV.1/8 51 <br /> EH 14-26 �( '�"1 �.� 90-3-4o3 <br /> 0' 3.4o3 <br />