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4 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T 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. <br /> iAl <br /> Job Address '51 'LCitysa C:' �;� Lot Sizer / PM <br /> M7 Y U _ ,4r-1e *7 <br /> �Tr ,11 Phone <br /> Owner's Name — � - L11' <br /> . Z"� !�G' Address k h <br /> r Contractor Se Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 17WELL REPLACEMENT ElDESTRUCTION ❑ <br /> PUMP INSTALLATION'❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> 3 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 /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public n Other 171 Delta Depth of Grout Seal Type of Grout _. <br /> I I Irrigation —.-Approx. Depth I1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ` ❑ Well Diameter Sealing Material atop 501 <br /> Depth Filler Material ;Below 50'] — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIR/ADDITION [ I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.i Q <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 a No. Compartments <br /> PKG, TREATMENT PLT. ❑ <br /> Method of Disposal \' <br /> Distance to eardst`:' Well FOUndati n Property Line <br /> v Ve ex lreO WILTout <br /> LEACHING LINE ❑ No. & Length of fi(n� e&flplated t)r ]IJISDaC f length/size <br /> FILTER BED ❑ Distance to neatm ell Gr �ll � Property Line <br /> bY v1rQrlrx { T1G�tt it <br /> SEEPAGE PITS I I Depth - Size Number <br /> SUMPS ❑ 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, 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,l shall employ persons subject to workman's compensa- <br /> tion taws of California." <br /> Theappy t must call for all required inspections. Complete drawing on reverse side. <br /> Signed X T Title: Date: <br /> FOR <br /> DEPARTMENT USE ONLY <br /> Application Accepted by Dated._ Area ,1 <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: -KZ--k <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca. a23-7104 ❑ 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 /> FEE AMOUNT DUE AMOUNT REMITTED cRECEIVED BY DATE PERMIT NO. <br /> INFO — CASH <br /> ♦.EH 13.24 IREV.1/K 51 3 <br /> EH 14-2e <br />