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b APPLICATION FOR PER <br /> � MIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON ON 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.. �� t <br /> ._w f <br /> Job Address ,._ City Lot Size <br /> 7 PM <br /> Owner's <br /> Owner's Name Address a` T ^; � -ger o4 <br /> Contractor ddressA - L TSLiceM1se No. c' -" Phoneme_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ .-,WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ l <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 % El Open Bottom C1Manteca Dia. of Well-Excavation Dia. of Well Casing <br /> (!Qomestic/Private } ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F Public ❑ Other f.-1 Delta Depth of Grout Seal Type of Grout _. <br /> I I Irrigation __Approx. Depth I I Eastern ��Surface Seal Installed by t <br /> Repair Work Done ❑ Type of Pump -ea-ets� H.P �` State Work pone V <br /> Well Destruction ❑ Well Diametern i <br /> Sealing Materia! flop 50'1 <br /> Depth Filler Material (Below 501 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION ! I DESTRUCTION ! I (No septic system permitted if public sewer is , <br /> �-+ 4 available within 200 feet.) <br /> Installation will serve Residence-C-ommerc6l 4- Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ElType/Mfg Capacity Na. Compartments <br /> PKG. TREATMENT PLT. [J1 <br /> k, Method of Disposal <br /> y Distance to nearest: Well Foundation Property Line d <br /> LEACHING LINE ❑ No. $ Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size _ Number <br /> SUMPS L� Distance 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 county ordinances, state laws, ander <br /> rules and regulations of the San 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 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 cornpensa- <br /> tion laws of California." <br /> The applicant must call r all requireV specfi6ns-tomplete drawing on reverse side. <br /> Signed X Title: <br /> Date: <br /> *OARTIMXENT USE ONLY""" <br /> Application Accepted by Date �7 <br /> Area �G <br /> Pit or Grout Inspection by Date <br /> 'Final Inspection by Date 9 /�-- <br /> Additional Comments: + <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823,71.04 ❑ Tracy 635-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.,.Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMO�DUAMOUNTREMITTEDCKINFO CASH RECEIVED BY DATE PERMIT'NO. <br /> EH 13-21 IREV. ,3 /' <br /> EH 1A-29 L•� <br /> 3 <br />