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4 • <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 /> c. <br /> -made in compliance with San Joaquin County O inance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. p <br /> t r <br /> Job Address City Lot Size v""' --^ PM <br /> 1 Phone <br /> Owner's Address Name _ .- <br /> k rV4 } L/Q 79 �i 22 <br /> Contractor _ ddress /� License_No!av` Phone a^�_ ` <br /> TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP I TALLATION-0❑ SYSTEM REPAIR ❑ OTHER 1-1 s <br /> DISTANCE TO NEAREST: SEPTIC TA t SEWER LINESISPOSAL FLD. PROP. LINE ��� <br /> I' FOUNDATION AGRICULTURE WE OTHER WELL PITS/SUMPS r <br /> ` INTENDED USE TYPE OF WELL PROBLEM AREA NSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom _ ante Dia. of Well Excavation Dia. i f Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack r ❑' Type of Casing Specifications <br /> ❑ Public ❑ Other , Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation �pprox. th ,❑ Eastern Surface-Seal Installed by--t # <br /> Repair Work Done -❑ Type of p H•P• R r - State Work Done <br /> Well Destruction ❑ iarn er �f Sealing Material v,50'I t c <br /> r Depth Filler Material (Below <br /> TYPE OF SEPTIC WORK NEWJNSTALLATION ❑ REPAIR/ADDITION ❑ ADESTRU N ❑ (No`sep`tic system permitted if public sewer is ' <br /> available within 200 feet.) <br /> r Installation will serve:,�Residence—'-Commercial__ Other ; <br /> r Number of living units: Number of.bedrooms _ <br /> Character of soil to a depth of 3 feet: �� r Water table-"' th <br /> SEPTIC TANK ❑ Type/Mfg FUL Capacity No.­Compartments r- i <br /> PKG. TREATMENT PLT- <br /> ^� Method of Disposal. j <br /> � , � <br /> - Distance'to nearest: Well,', 9/9 Foundation Z 11_ Property Line — <br /> _ � r, <br /> LEACHING LINE: No.�&�Lerlgth of lines i Total length'/size <br /> z <br /> rI <br /> FILTER BED - —❑—Distance-toLnearest: Well Property Line <br /> SEEPAGE PITS ❑ Depth YSize '--Number <br /> f <br /> SUMPS ❑ Distance to'nearest-.' Well Foundation 5EoA -Property Line <br /> ( DISPOSAL PONDS t <br /> El '! <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. f ' <br /> Home owner or licensed agent's signaturecertifies-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 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 /> i tion laws of California." <br /> The appiican ust call for all squired ins ctions. Complete drawing on reverse side. f <br /> I Signed r Title: Date: y J ' <br /> I FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date / Area �f <br /> Date-L—Al <br /> Pit or Grout Inspecit ofion'by Date Final Inspection by } <br /> E /AddI Comments:`/� T�r /n 0 <br /> �. _. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy U �ByL <br /> Applicant-,Return ali copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 } <br /> FEE gMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. <br /> INFO _ <br /> J+'EH13441REV.1%e�51' <br /> EH 1428 <br />