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4 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> t Telephone (209) 466-6781 <br /> t PERMIT.EXPIRES 9 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.. <br /> r ��� <br /> Job Address -��� City-5, I2CZ&Y Lot Size 'g_pM <br /> Owner's Name Address 4 Phone9�W-278-,9'aid <br /> r <br /> � Contractor. _ <br /> Address License No. �, Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> k PUMP INSTALLATION ❑ SYSTEM REPAIR ❑Y OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> --"`-` FOUNDATION ^----7 AGRICULTURE WELL`"" -�'� ---OTHER WELL -' ' PITS?SUMPS <br /> INTENDED=USE _NPE OF_WELL_i-.'PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> CI Industrial ❑ Open Bottom ❑ Manteca iDia.,of.Well Excavation ­� --h , Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy s Type of Casing. Specifications <br /> I <br /> _11Public _s <br /> Delta-* - Depth of Grout Seal r r <br /> f I Irrigation .-.' „ _ '"'.Type of Grout _ <br /> g' _.Approx. Depth I I Eastern Surface SealInstalledby - <br /> Repair Work Done L7 Type of PumpH-p. �°,` F - <br /> _ State Work Done_ <br /> Well Destruction ❑ Well Diameter t Sealing Material (top 5( j <br /> Depth Filler-Material (Below 50') l ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION l DESTRUCTION I I INo Septic stem <br /> ' p y permitted if public� sewer is available within 200 feet.)r ^"� <br /> Installation will serve: Residence ✓ Commercial Other- - � /fdix <br /> Number of living units: -I-Y— Number of bedrooms'_. . a <br /> Character of soil to a depth of 3 feet: _/ .` ,- r i •"`ti y / <br /> Water table depth G <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line_ S <br /> c - <br /> LEACHING LINE ❑ No. & Length of lines ' `Total length/size a <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> i a Property Line <br /> SEEPAGE PITS Depth Size .. <br /> ' '" .' �Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property.Line <br /> DISPOSAL PONDS ❑ } r i <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, and <br /> rules and regulations of the San Joaquin Local Health District. I - <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 J <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ <br /> tion laws of California." p y persons subject to workman's compensa- <br /> The applicant mu call for all r Mnvctions. Complete drawing on reverse side. <br /> Signed X <br /> Title: <br /> F• - . ate: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 7� <br /> Date Area ll <br /> Pit or Grout Inspection Date Final In ec ion by n� <br /> _ Date D <br /> Additional Comments: A_-0_-0 <br /> ❑'Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1323-7104 ❑ Tracy 835-63135 1 <br /> Applicant - Returri all copies ta: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 > <br /> FEE AMOUNT 6UEI- AMOUNT REMITTED C <br /> INFO CASH RECEIVED BY DATE PERM17•NO. <br /> 7O ' l <br /> +.EH14-24tpEV.iiHs) / !lL911 <br />