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'� I! 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 /> �I (Cornplete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described. This applicatirxl 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 oistrict. <br /> l' -91=4—b4 <br /> �� <br /> Job Address City Lot Size PM <br /> aoScaD <br /> Ownei s Name � Address � Phone <br /> ` tips s Q <br /> Contrac �� Address� . License No i o Phone <br /> TYPE OF WELL/PUMP: it NEW WELL ❑ WELL REPLACEMENT C <br /> DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> 01STANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Welt Excavation s Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑Tracy YP 9 Type of Casin t <br /> Specifications, <br /> f Public M Other 17 Delta Depth of Grout Seal Type of Grout <br /> I Irrigation ,..Apprax, Depth I 1 Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump <br /> H.P. State Work Done <br /> Well Destruction O Well Diameter � ..' <br /> Sealing Material (top 50'] <br /> Depth I� Filler Material IBelow <br /> TYPE OF SEPTIC WORK: NEWq.INSTALLATION 11 REPAJR/ADDITION' ESTRUCTION t I (No septic system permitted if public sewer-is Installation will serve: Residence ^- Commercial available Other within 200 feet.) �, I <br /> Number of living units: Number of bedrooms�► - t[ <br /> Character of soil to a depth of 3 feet:­ SAJ&b Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Ca act j <br /> a P ty No. Compartments tf <br /> PKG. TREATMENT PLT.❑ sMethod of Disposal <br /> t i <br /> Distance to nearest: Well WO Foundation�, Property Line <br /> I _ i <br /> LEACHING LINE No:'& Length of lines Total rengih/size <br /> FILTER BED ❑ Distance to nearest: Wetly Foundation Property Line <br /> f �v-_ <br /> SEEPAGE PITS I I Depth Size <br /> Number <br /> SUMPS 0 Distlsnce to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin countyro dinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Di�trict. <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 /> P any y person in h manner'as to become bieci to workman s•c6mperisetian laws Df California:"'Contractor's-hiring orsub-contracting signature <br /> certifies the following: I certify that in the pe rf hce of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of CaGfo 1 <br /> The appli nt t U for all requir ns coon Co ete <br /> ng on reverse side. <br /> Signed X <br /> Title: Date: 7�1 <br /> FOR DEPARTMENTTUSE ONLYApplication Accepted byaDate AreO i <br /> Pit or Grout inspection by Date Final In ej <br /> spection by `Date // /`7 <br /> h l <br /> Additional Comments; — <br /> ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7184 D TrecV­­835-M---- <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1681 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201` <br /> fI A <br /> FEE <br /> AMOUNT DUE AMOUNT REMITTED CK i <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> a.EH 1;-24(REV.r/a 55 'II <br /> EH 1426 '��b •�[►C/�t <br /> 9 V 1 <br />