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?" APPLICATION FOR PERMIT <br /> ?� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.-HAZEL T ON AVE., STOGKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROMIDATE ISSUED , <br /> (Complete-in Triplicate) <br /> II <br /> Application is hereby made to the San Joaquin Local Health{District for a permit to consttuct 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 /> Job AddressA57 , City Lot Size 60A,. mS, M <br /> Owner's Name /C Glc Cbi ar[ T BN�s1r j Address 11 <br /> Phone <br /> Ik . <br /> Contractor * Address i l License No.fq7_? L+ Phone_ <br /> TYPE OF WELL/PUMP: NE%WELL^^ ❑T WELL REPLACEMENT ❑_ DESTRUCTION ❑ <br /> PUMP If STALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES,, DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL it 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 /> I <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing II Specifications <br /> {'1 Public ❑ Other F) Delta Depth of Grout Seal Type of Grout <br /> I Irrigation _.-Approx. Depth I 1 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'I{ <br /> Depth Filler Material (Below 501' I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I I DESTRUCTIONX Mo septic system permitted if public sewer is � <br /> i available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other I� <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 lines + Total length/size E <br /> 4 <br /> FILTER BED ❑ Distance to nearest: Well "- -Foundation . I+ Property Line <br /> iiI <br /> SEEPAGE PITS I 1 Depth Size Number <br /> r <br /> SUMPS ❑ Distance to nearest: Well Foundation I Property Line <br /> DISPOSAL PONDS ❑ 2 \ <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 j <br /> rules and regulations of the San Joaquin Local Health Di§trict. t q I <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, t 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 i <br /> certifies the following: "I certify that in the performance of the work for which this perdt is issued; I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applica ust all f all re=' ins ctions. Complete drawing on reverse side- <br /> I! t s 1 <br /> Signed X Titre: ;' t`Y Date: I <br /> FOR DEPARTMENT USE ONLY ! <br /> Application Accepted by ; Date <br /> Pit or Grout Inspection by Date Final Inspection by <br /> I! <br /> Additional Comments: 'I <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 y ve., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT�R+EMkTTEO CASH R�ECEIIVED BY DATE PERMIT'NO- <br /> EH 13-24(REV,vixsl �J ` y // / / <br /> EH 1429 J (!yi'Li ( {P 1 <br />