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a <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,,STOCKTON, CA <br /> Telephone (2091 4W-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 welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address <br /> City T Lot Size PM <br /> ?4 S�E/4 ' —,..4 �_. -- Phone 95 -73 �%4 <br /> Owner's Name /,l .1°d ddress �-, — _--._ : <br /> Phone <br /> TYPEContractor's Name ,���,!/g1H�ense No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ - DESTRUCTION ❑ <br /> PUMP INSTALLATION,' RSR q4,=,",$X*EM REPAIR El OTHER,LJDISTANCE TO NEAREST: SEPTIC CD <br /> TANK SEWER LINES DISPOSAL F . PROP"LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom F-1 Manteca <br /> X Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 17''Public <br /> ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern ! Surface Seal Installed by <br /> Repair Work Done E3 Type of Pump �!>l H.P.— �� State Work Done <br /> 1/iI y T'Ad /d JE�IN$fJC <br />[ Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION CD REPAIR/ADDITION ❑ 'DESTRUCTION El septic'sysfem 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 /> -. Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity. No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal C. <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size ` <br /> i <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE ?ITS--­711 Depth-or-4,L...�� Size""""�'_. `�:=— _ Number f <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 /> j 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 /> FI employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> I certifies the following:"i certify that in the performance of the work for which this permitis issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call f�r II required inspections. Complete drawing on reverse side. <br /> Dat <br /> Signed Title: <br /> eA <br /> FOR DEP RTMENT USE ONLYZ— <br /> i <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection Date <br /> XAd itional Comments. ' <br /> Stk 466-6781 ❑ Lodi 36.9-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2(100, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> + EH 13-24[REV.10/831 <br /> I EH 14-26 <br />