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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i 1601 E. HAZELTON AVE.,'STOCKTON, CA <br /> Telephone QW) 466-6781JAN <br /> 1 € '0 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ENVIROM ENTAL HEP LTH <br /> PERMIT/SERVICLS 1 <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—' niw' s <br /> Job Address City-0 <br /> ity- �, Lot Size PM <br /> Owner's Names Address Phone <br /> f Contractor_CAI_,1VPr1z40,110&.&96ess `S` ense Nol���2i_11-2 Phod;19,*12 <br /> TYPE OF WELL/PUMP: NEW WEL WELL RE LACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑, SYSTEM REPAIR ElOTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKIR-47 7 SEWER LINES Fl DISPOSAL FLD. PROP. LINE t� <br /> t FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> , INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS y <br /> p��I�nd'ustrial ❑ Open Bottom ❑,,..lm,�Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Ir UOmestic/Private ravel Pack (d l racy Type of Casin Cit- Specifications <br /> � Public b?�� ❑ Other ❑ Delta Depth of Grout Seal a� 5_%Type of Grout <br /> Li Irrigation s <br /> PApprax. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ElType of Pump �" ' H.P. State Work Done "A <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50 <br /> Depth ' Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION C71REPA /ADDITION ❑ DESTRUCTION Ll (No septic system permitted if public sewer is <br /> . w available within 200 feet.) <br /> i Installation will serve. Residence_ Commercial , Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: t Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 1' -Capacity No. Compartments <br /> P•KG. TREATMENT.PLT. ❑, � N �k Method of Disposal <br /> Distance tonearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. &Length of tines Total length/size <br /> FILTER BED i 11y Distan{c{e to nearest: Well Foundation Property Line <br /> r fes, • . • <br /> T t esEEPAGE PITS', ❑ Deptht Size 0 Number <br /> ' SUMPS r ❑ Distance to nearest: - Well- —Foundas'tiorl� f '"Property.Line w' T <br /> DISPOSAL PONDS -❑ _ <br /> r I hereby certify that I have prepared'this application and that,tKe"wor awill"be done in accordance with San Joaquin county ordinances, state laws, and 4 <br /> " 4 rules and regulations of the San Joaquin Local Health District. i Y � i <br /> . Home owner or licensed agent's signature certifies the fol certify that in the performance of the work for which this.permit is issued, I shall not 1 <br /> T{-employ any person in such manner as to become subject to•w'orkman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following:"I certify that in.the performance f the work for which this permit is issued,I shall employ persons subject to workman's compensa- i <br /> ,•tion laws of .�Califdrnia.'� <br /> i 1 - ' - . <br /> The applicant must al or atl_ fired,inspections. Complete drawing on rev side. <br /> I1, r a .--_ <br /> f Signed Title: E Date., <br /> f FOREPARTMENT USE Y _„ - <br /> F -_ <br /> � ! t <br /> Application Accepted by' Date Area t <br /> Pit or Grout Inspe tion by;.. . Date Final Inspection by "I Data . <br /> Additional Comments: <br /> ❑ Stk 466.67814^—E] Lodi"369-3621 1 ❑ Manteca .823-7104 ❑ Tracy <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA SM01 <br /> INFO AMOUNT DUE t AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. <br /> +EH 13-24(REV.t/65Y i / pU ( -� <br /> EH 1428 <br />