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1 6. <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> LLocal Health District h A I C <br /> Job Address .�� 0 v`r< .V/y Fn Z City Lot Size PM <br /> L111l <br /> Owner's Namr-1,CJ IL-1' SIU 1 Address Phone <br /> Contractor Address License No. !Phone 9 a_a� <br /> { TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1DESTRUCTION ❑ <br /> L PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE _ <br /> [ FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS <br /> LINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Lr"I Public Ll Other F1,Delta Depth of Grout Seal Type of Grout_ _ <br /> 1 Irrigation —Approx. Depth I I Eastern Surface Seal Installed by _ <br /> Repair Work Done Ll Type of Pump H.P. State Work Done <br /> LWell Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> L Depth Filler Material (Below 501 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ESTRUCTION I I (No septic system permitted if public sewer is <br /> ' available within 200 feet.) O <br /> Installation will serve: Residence L <br /> _ Commercial— �Other <br /> Number of living units: I_ Number of b Brooms --.� <br /> Character of soil to a depth of 3 fee 6MLC74,rl Water table depth <br /> LSEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments /ems <br /> L PKG. TREATMENT PLT. ❑ .Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LLEACHING LINE N-& Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> ( SEEPAGE PITS Id--Depth Size un1ber OA <br /> Lr SUMPSLl Distance to nearest: Well Foundation Property LineKC <br /> DISPOSAL PONOS ❑ <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 /> 6. rules and regulations of the San Joaquin Local Health Di-strict. <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 became subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the followmg-�_'J.y rtify that in the performance of the work for which this permit is issued. I shall employ persons subject to workman's compensa- <br /> tien�a�Jtr Califorpp{{,,la." <br /> 4' The applim m Nall for all r air ins c ions. o <br /> 1 dl .awing oD revar ty; �y7 Hyl <br /> SSg 2 id <br /> /�-) _ Date: / -/- U C\ <br /> ... i// s/FO�RTMENT USE ONLY _ _1j <br /> Application Accepted by % � Date / Area <br /> Pit or Grout Inspection by Date Final Inspection by Data r� -4)r <br /> tiyt:'f <br /> Additional Comments: 'f 61 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0-Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CK A CASH RECEIVED BY DATE PERMIT NO. <br /> ✓ EH 1324 IREV.11.51 /' - -> <br />