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. 1 <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 /> Local Health District. <br /> Job Address 3635 Country Club Stockton 95 x 192 <br /> Ciry Lot Size PM <br /> Owner's Name EDWARD ZUCKERMAK Address 3635 Country Club <br /> __ Phone <br /> Contractor's Name JF5tRy JOY 6 ASSOC. License No. 394241 <br /> Phone 462-1481 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial D Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑'►racy Type of Casing_ _ Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation <br /> ­-Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Seating-Matenal (top 501 _ <br /> Depth Fdler Material(Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ ,REPAIR/ADDITION DESTRUCTION ❑ (No septic system y permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence 15- Commercial Other <br /> Number of living units: 1 Number of bedrooms_ <br /> Character of soil to a depth of 3 feet: 1 Water table depth <br /> SEPTIC TANK ❑ Type/Mfg �'`�1 a 1-I f'l� C C'YV`PCanwrity No. Compartments \ <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation_ Property Line_ <br /> LEACHING LINE T1 No. 8 Length of lines one Total length/size. nint feet <br /> FILTER BED D Distance to nearest: Well g 12' rr y 1 <br /> Foundation Property Line 5 <br /> SEEPAGE PITS ❑ Depth Size Number _ <br /> SUMPS D Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS D <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 regulatiorn of the Sen 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 ea to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following. "I certify that in the performance 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 must for an requ' inspections. Complete drawing on reverse side. <br /> Signed T-nie• C Q-� �lA(- �1 a <br /> Date: .. l <br /> FOR DEPARTMENT USE ONLY Q C <br /> Application Acce l by 1�\ Data I I -(}�S Area 1 <br /> Pit or Grout Inspection by DateFinal Inspection by—,kA O�(C � C� Data <br /> Additional Comments: <br /> ❑ Stk 4666781 ❑ Lodi 363-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Envirorvnental Health Permit/Services 1601 E. Hazetton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CA H RECEIVED BY DATE <br /> PERMIT NO. <br /> + EH 1325 IREV. 10/83l ) �1 <br /> EH 14-25 � CIO 7- <br />