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r.:.0 <br /> APPLICATION FOR PERMIT <br /> � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT } <br /> AVE., STOCKTON, CA <br /> 1601 E. HAZELTON <br /> Telephone (209] 466-6781 19$3 <br /> i J S � N <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , <br /> I <br /> (Complete in Triplicate) CNV1f2011yN1ENikl.A+°+UH <br /> RW Ilion is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein d <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Reguabohs of the San Joaquin <br /> k Local Health District. <br /> Job Address <br /> 900 SouCity Z I Lot Size ZOD x250 PM <br /> 66 <br /> Owner's Name <br /> N (} '�]G Address QDO Sov �Q Phone 273 <br /> II 7 <br /> Contractor —F—sr <br /> Address License No. <br /> §767qPh <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ !� ,i <br /> PUMP INSTALLATION ❑ SY51 EM REPAIR fl OTHER PrIPE6 we 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> N <br /> � INTENDED USE ,TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO <br /> ❑ Industrial ❑'Open Bottom ❑ Manteca Dia. of-Well Excavation M Dia. of WellCasing <br /> ❑ Domestic/Private W ravel Pack ❑ Tracy Type of Casing Specifications �`. ,- <br /> i`I Public ❑ Other ❑ Delta Depth of Grout Seal Type of Gro tCJt� <br /> I i Irrigation _..Approx. Depth i I Eastern Surface Seal Installed by I` <br /> Repair Work Done ❑ Type of Pump _— �_� H.P State Work D ne, I <br /> r Ip' <br /> Well Destruction ❑ Well Diameter � Sealing Material atop 50'1 AMID Q <br /> I1 <br /> ,e al Depth lam— Filler Material iBelow 50'1 <br /> I TYPE OF SE IC WORK: NEW INSTALLATION I') REPAIR/ADDITION I 1 DESTRUCTION I 1 {No septic system permitted if public sewer is <br /> i, available within 200 feet.) f <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 ❑, Type/Mfg <br /> Capacity No. Compartments 'N <br /> PKG. TREATMENT PLT. ❑ Method of Disposal �- <br /> ! Distance to nearest: Well Foundation Property Line i <br /> LEACHING LINE ❑ No. & Length of lines Total length/size— <br /> FILTER <br /> ength/size FILTER BED ❑1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l 1! Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Q: �. <br /> I hereby certify that l 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. <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 compensa- <br /> tion laws of California." <br /> ,; 16 <br /> The applic ust call for RJI req 7d ins tions. Complete drawing on r verse side. I� <br /> Signed Title: Date: <br /> d <br /> D NT USE ONLY <br /> N Date J `G�r Ar <br /> ll <br /> Application Accepted by - <br /> I / <br /> Pit or Grout Inspection b rl Date Final Inspection by p Dat/Z�i—I <br /> �I <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201-771 <br /> FEE AMOUNT DUE AMOUNT REMITTEDH RECEIVED BY DATEcAg <br /> PERMr7 N0. <br /> INFO y <br /> +.ER13-24(REV.I <br /> EH 14-26 <br />