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a <br /> APPLICATION FOR PERMIT` <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> j I (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 /> 2107 Wet Lane Stockton <br /> I � Job Address i. City Lot Size PM <br /> I <br /> H. LEROY MINATREE Address P 0 Box 8117 Phone 941-2921 <br />[ / Owner's Name <br /> H. LEROY MINATREE P O BOX 8117 941-2921 <br /> Contractor .E. Address License No. Phone <br /> TYPE OF WELL/PUMP: I` NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTA'ON <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEREST: SEi'TIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION RIC LTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED TYPE OF WELL PROBLEI I AREf CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial - ❑ Open Bottom ❑ Mant an,.. of 164011 K OiiAla <br /> ❑ Domestic/Pri ❑ Gravel Pack LJTracy _ Type of Casing Specifications <br /> r FI Public ❑ IOCher Cl Delta Depth of Grout Seal Type of Grout <br /> r I I Irrigation <br /> Approx.,Depth i I EasterSu d by - <br /> Repair Work Done y❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter A Seali g Ferll.wp 1 Filler rial ) <br /> TYPE OF SEPTIC ORK: NEW INSTALLATION I I RE AIR/ TIO I I DESTRU TIO (No septic system permitted if public sewer is <br /> IIII available within 200 feet.I <br /> Installation will rve: Residlence— Commercial `+ t r .-- -__Y__ <br /> Number of livin units: J Number of bedrooms �lU f�� a <br /> Character of soil to a depth of 3 feet: <br /> h' <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ I� /� Method of Disposal <br /> �4Distance to nearest: Wel oundation Property Line <br /> II � <br /> i LEACHING LINE ❑ No. & Length of lines Total length/size <br /> kh <br /> FILTER BED ❑ Distance to rtearest: Wel Foundation Property Line <br /> SEEPAGE PITS 1.1 Depth Size _ Number <br /> SUMPS ❑ Distance to nearest: Wel Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that i have prepared this application and th t the vork will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Dist ct. <br /> I Home owner or licensed agents signature certifies the follo ing: '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 ovork an's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following: "I ertif//tha n the performance of tt a worl for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Californi ' <br /> i� <br /> The applicant, a uired ti s om de dralving on reverse side. <br /> Signed X �F T tle: Owner Date: 3/,21/8 9 <br /> / �i <br /> OR EPAR ENT USE ONLY 10 `� <br /> Application Accepted by � Date �J� � Area D <br /> Pit or Grout Inspection by 0. Date Final Inspection by Date 3 Z 2" <br /> Additional Comments: 'M <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies fo: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'.NO. <br /> INFO a CASH <br /> +.EH 1324 IREV,I/1151 �� �� , O C - tl• � �`'7 t �s r <br /> EH 14-2e <br />