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-' EN ­4 <br /> APPLICATION FOR PERMIT <br /> ,1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> . 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> to_Y PERMIT EXPIRES 1 YEAR FROM DATE ISSUED *' <br /> .I <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora 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. ! y <br /> rt .i <br /> Jab Address City C t Size <br /> AOwner's Name _ IIr "'IO � IfCf Address �1VL C _ Phone <br /> A ' <br /> Contractor's Name License No. / 0 � Phone �- <br /> TYPE OF WELL/PUMP:, NEW WELL © WELL REPLACEMENT E]-., DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑�. SYSTEM REPAIR faL- .� OTHER ❑ <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 /> C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well-Casing <br /> Qomestic/Private © Gravel Pack ❑ Tracy ,4 ype of Casing Specifications - <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout F' <br /> ❑ Irrigation —Approx. Depth /7 Eastern SurF a Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> Well Destruction Well Diameter Sealing Material (top 501 ` <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION C7 DESTRUCTION ❑ (No septic system periitit{ed if public sewer <br /> available within 2*6E u J <br /> Installation will serve: Residence= -Commercial— 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 ❑ 1Type/Mfg Capacity No. Compartments*;.- <br /> PKG. TREATMENT PLT. El..,. f Method of Disposal <br /> Distance to nearest: Well Foundation Property Line r <br /> LEACHING LINE ❑ No. & Length of}lines Total length/site A <br /> FILTER BED ❑ Distance to nearest: Well ,iM, Foundation Property Line <br /> SEEPAGE PITS ❑Depth Size Number <br /> SUMPS �❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and.that the work ill be done-iriaccordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District:` r- . <br /> Home owner or licensed agent's signature certifies,the'following: "I cerirfy:that in theperformance of the work for which this permit is issued, I shall not H <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 performanc of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> i <br /> The applPa�apt-must c for all required 1 ctio .'Co late drawing 10 verse side. / <br /> Sig nedTitle: li � _ Date: TX� <br /> ` FOR DEPARTMENT USE ONLY <br /> 4 tC <br /> / - <br /> Application Accepted by � Date +-2b�O � Area <br /> Pit or Grout Inspection by Date . Final Inspection by Date <br /> J 'a f, 1 <br /> Additional Comments: =. f <br /> ❑ Stk 466-6781 3 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services'1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i� <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED r, CASH CK 4 RECEIVED BY DATE PERMIT"N0. <br /> + Eli13-241REV.10/83) <br /> EH 14-26 S ao � o .. �Sb iSlcao <br />