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1 <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 /> 1. , (Complete in Triplicate), <br /> ')V% <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. TNs application is <br /> ! made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1852 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District.' <br /> • tt t ,r <br /> •- City <br /> A� Lot.Size PM <br /> Job Address <br /> J7el(�N15 Q�f UE3aC Cr� rr1E�-THh Ur�� z _ <br /> Owner's Name - Address �-�d7� 1 i�RI1 � Phone <br /> � r <br /> /ff/9A'd-lJ 0 /OUn1,0I�Q OP License No. kO `95-" Phone <br /> Contractor Address, 6' <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ O <br /> PUMP INSTALLA�TII,O,N, SYSTEM REMh ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ���, SEWER.LINES.—.DISPOSAL FLD/0j— PROP. LINE <br /> FOUNDATION AGRICULTURE WELL // ;OTHER WELLPITS/SUMPS <br /> �. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial Open Bottom Ll Manteca Dia. of Well Excavation ' Dia. of Well Casing CCS <br /> Domestic/Private Gravel Pack El Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ' ❑ Delta Depth of Grout Sealf Type of Grout ,U <br /> 777 <br /> ❑ Irrigation ----4pprox, Depth ❑ Eastern Surfac Seal Installed by— <br /> Repair <br /> y Repair Work Done ❑ Type of Pump H.P. - State Work Done <br /> 4 Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 , <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION El DESTRUCTION ❑ INo 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 /> i table depth <br /> Character of soil to a depth of 3 feet: <br /> Water � <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartme is <br /> i <br /> PKG. TREATMENT PLT. ❑ Method of,Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. &Length of lines Total length/sze �r <br /> FILTER BED ❑- Distance.to nearest: Well .Foundation - ­'Property-Line- <br /> = '`. <br /> SEEPAGE PITS F 11 Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundations Property Line ' <br /> DISPOSAL PONDS ❑ r <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 shatl not <br /> f California." Contractor's hiring sub contracting signature <br /> employ any person in such manner as to become subject to workman's compensation laws oct to workman's compensa <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, f shall employ persons subject <br /> tion laws of Calif <br /> The applica st call for all required ins ctions. Comp) to dr ing on reverse side. —4F6 <br /> j <br /> Signed Title: Date:Y—/s 6 <br /> FOR DEP RTMENT USE ONLY Q <br /> D <br /> Application Accepted by ate fJ Area <br /> ! - � <br /> j Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ 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 /> nIFPE _MOUNTDUE AMOUNT REMITTED CASKRECEIVED BY DATE PERMITNO. <br /> $(y- 1013 <br /> + EH 13.24 1 REV.i/n 5) <br /> EH 1428 " <br />