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. APPLICATION, FOR PERMIT g <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZE T ON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES YEAR FROM DATE ISSUED <br />(Complete in Triplicate) �. <br />OC 13 -1984 <br />is <br />SAN J WUIN LOCA:.' r <br />HEALTIN DISTRICT,, <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 wail/pump and the Rules and Regulations of the San Joaquin <br />Local Health District.a t : <br />, <br />f <br />' �f7KTD 't vsr ,.:,r11©'a: P x <br />1-k AAA. ---r f`in, I n+Civn PAA <br />Owner's Name t?77E `+6;17/t�i� vAddress - �! � - - T Phone - <br />Contractor's Name Afim1pa I ( License No. �3 7 Phone <br />TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br />PUMP INSTALLATION 9— .SYSTEM REPAIR ❑ 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 />❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br />,KQomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br />❑ Public ❑ Other ❑ Delta Depth of Grout Seal _. Type of Grout <br />❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br />Repair Work Done Type of Pump 24 H.P. State Work Done <br />Well Destruction ❑ . Well Diameter Sealing Material (top 50') <br />Depth &s- Filler Material (Below 501 <br />TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br />available within 200 feet.) <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 Capacity No. Compartments <br />PKG. TREATMENT PLT. ❑ Method of Disposal <br />Distance to nearest: Well Foundation Property Line <br />LEACHING LINE ❑ No. & Length of lines Total length/size <br />FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br />SEEPAGE PITS ❑ Depth Size Number <br />❑ Distance to nearest: -Well -foundation Property Line <br />DISPOSAL PONDS ❑ <br />�a <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. r <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." Contractors 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 />The applicant must call for all required inspection' Complete drawing on reverse side. <br />Signed �Title: Date:. <br />FOR DEPARTMENT USE ONLY <br />Application Accepted byw Date Area <br />Pit or Grout Inspection by Date Final Inspection by �'�:r.�- •9ate i`–i--$ <br />,A5011tlonal Comments: <br />Stk 4664781 - ❑ •Lodi 369-3621 ❑ Manteca 823-7104 Q 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 />EH 13-24 (REV. 10183 <br />EH 1428 <br />FEE <br />INFO <br />-AMOUNT DUE <br />AMOUNT•• REMITTED <br />CASH RECEIVED BY <br />DATE ` <br />PERMIT "NO. <br />