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I <br /> APPLICATION FOR PERMIT <br /> ' i <br /> SAN JOAQLlIN;LOCAL'HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES'l YEAR FROM DATE '1S$UED <br /> 4 (Complete in y�Triplicatel , y ♦�{ ' <br /> Application is hereby made tD 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. 6.t:41 <br /> I <br /> Job Address Q � Cityf iLot Size rPM <br /> cfr <br /> Owner's Name Address Phone - <br /> Contractor _Address/ d �7_ License No --(. 23 3 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑'" WELL REPLACEMENT ❑ DESTRUCTION ❑ ' <br /> PUMP INSTALLATION ❑ \\;SYSTEM REPAIR LY 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 /> Ci'6omestic/Private ❑ Gravel Pack El Tracy' Type of Casing Specifications <br /> ❑ Public ElOther ' ' yCl-Delta i Y Depth of Grout Seal Type of Grout' <br /> ❑ lrrigation­ --Approx. Depth ^❑ Eastern Surface Seal Installed by u r <br /> Repair Work Done Q' Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501)'- (7 <br /> Depth Filler Material (Below 50'), <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 I Commercial_ Other17 <br /> Number of living units: Number of bedrooms F <br /> Character of soil to a depth of 3 feet Water table depth T ' <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �J <br /> PKG. TREATMENT PLT. ❑ Method of Disposal /OV <br /> i <br /> Distance•to nearest: Well Foundation Property Line <br /> LEACHING LINE F-1y-No.&_Lepngth,-ofJines. Total length/'size -- 5 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ 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,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> F . <br /> The applicant m t all or all re d inspections. Complete drawing on re_ve_rse side. <br /> Signed Date: <br /> FOR D PARTMENT U ONLY <br /> Application Accepted by I Date Area ' <br /> h � <br /> Pit or Grout Inspection by I� Date Final Inspection by Date `a <br /> I <br /> Additional Comments: <br /> ❑ Stk 466-6781 C7 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> ..Applicant - Return ail copies to: Enviroilrmental Health Permit/Services 1601-.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> - IIS � f. j _ • <br /> FEE <br /> W <br /> INFO AMOUNT DUES AMOUNT REMITTED CASH RECEIVED BY DATE;:. PERMIT"NO. e — <br /> + EH13-241REV.1/851 <br /> EH 14-28 S - ®� ` t��G' S <br />