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Aw— <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 5 i/G✓< f <br /> 1601 E. HAZEL T ON AVE.,,STOCKTON, CA f <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES;1 YEAR FROM DATE ISSUED <br /> ✓ �/ <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 Rules and Regulations of the San Joaquin <br /> Local Health District. _ <br /> ' f �X a <br /> Job Address C N Ij r City .'S f A-l 0 PM <br /> -.. Lot Size <br /> % <br /> Owner's Name ddress sla,-� " r �C r nJ V C Phone 6 <br /> I V <br /> Contractor Address " License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ ­.SWELL REPLAC_EM_ENT ❑ } DESTRUCTION❑ <br /> PUMP INSTALLATION _ SYSTEM REPAIR ❑ L -OTHER ❑ <br /> .. ., <br /> DISTANCE TO NEAREST: SEPTIC TANK ER LINES <br /> DI SPO FLD. PROP. LINE <br /> FOUNDATION AGR LTORE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL „'PROBLEM AREA RUCTIOMSPECIFICATIONS <br /> ❑ Industrial E2Open Bottom ElManteca Dia. Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ T Type of C " g Specifications <br /> ❑ Public ❑ Other Delta Depth of Grout al Type of Grout <br /> ❑ Irrigation _J4pprox.�Depth ❑ Eastern Surface Seal Installe by <br /> Repair Work Done ❑ Type of Pump H.P. ate Work Doneh <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> vailable 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 /> PKG. TREATMENT PLT. ❑ } Method of Disposal " <br /> Distance-to nearest: Well Foundation Property Line <br /> - i <br /> LEACHING LINE ❑' No. & Length of fines �r Total length/size , <br /> FILTER BED ❑ Distance to nearest: Well Foundation P-roperty_L-ine-•—� <br /> SEEPAGE PITS ❑ Depth Size °y F <br /> Number E <br /> SUMPS ❑ Distance to nearest: Well Foundation A Property Line <br /> DISPOSAL PONDS ❑ t r <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. r <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for vvNch•this <br /> employ an permit is issued, I shall not <br /> p y y 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 ust c I for all required 3pections. Complete drawing on reverse side. I.f i <br /> Signed X - <br /> Title: Date: ��d + <br /> FOR DEPARTMENT USE ONLY, <br /> Application Accepted byAef Date I' 2" ; " re_ <br /> 1 <br /> Pit or Grout Inspection by t Date <br /> " Final Inspection by Date <br /> Additional Comments: s D / 0.3 Q ,} � } S ( f/t/�Z V <br /> ❑ Stk 466-6781 ❑ Lodi 369-36214 ❑.Manteca 823-7104. ❑ Tracy 635-6385 " 4 n / <br /> Applicant- Return all copies to: Environ ntal Health Permit/Services.1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 PFI U5t } <br /> FEE AMOUNT DUE- AMOUNT REMITTED <br /> INFO AS /RECEIVED BY DATE PERMIT"N0. <br /> + EH 14-24[REV.t/H51 <br /> EH 14-28 _- <br />