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f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA J <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 /> Job Address <br /> City 5,vo, <br /> /� Lot Size PM <br /> Owner's Name , Address �.Jam- �/!R}rs. L <br /> Phone --- <br /> Contractor's Name License No./ 3 LEE 3 r C i <br /> Phone <br /> TYPE OF WELL/PUMP: NEW WELL ?" WELL REPLACEMENT ❑ DESTRUCTION ❑ - W <br /> PUMP INSTALLATION IS SYSTEM REPAIR ❑ OTH7R ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK JJ-f SEWER LINES /C,6 r DISPOSAL FLD. Z21 PROP. LINE <br /> FOUNDATION AGRICULTURE WELL ' OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE.OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom C1Manteca Dia..of Well Excavatio Dia. of Well Casing <br /> P15---estic/Private "ravel Pack LJ Tracy Type of Casing A � Specifications <br /> ❑ Public 0.Other ❑ Delta Depth of Grout Seal �� _n Type of Grout <br /> ❑ Irrigation /.2A_:Approx. Depth ❑ Eastern �urface Seal Installed by <br /> Repair Work Done ❑ Type of'Pump Si4-6— H.P. State Work Done <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material (top 501 <br /> Depth Filler Material (Below 501 jj <br /> .-�.TYPE OF SEP WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is . _J <br /> available within 200 feet.) <br /> Installation will serve: nce_ Commercial_ Other "" --- <br /> i <br /> Number of living units: Nu bedrooms ; <br /> Character of soil to a depth of 3 feet: Watert b depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments C <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 /> SUMPS ❑ Dista hce 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. f <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 Ca' nia-" i <br /> The applican II for fired inspections. Complete drawing on reverse side; <br /> Signed z o: 1V <br /> itle 1 Date: /r 0 <br /> FO EPARTMENT USE ONLY <br /> Applicati <br /> !nAcfepted by Date a { <br /> �j � 9 <br /> Pitr nspection by Date _Final Inspection by Date <br /> _ <br /> Additional Comments: 15,A- — �104(1104(1❑ Stk 466-6781 Lodi 3621 173 Manteca 823-7104 #- 'Tracy 835-6385 7-1-7 <br /> f / / <br /> Applicant- Return all c pies to: Environmental Health Permit/Services 1601 E"Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE F <br /> CK <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE <br /> �r rr PERMIT'NO. <br /> + EF!1}24IREV.10/831 ,�, ,� �r 7� <br /> EH 1428 (J V <br /> f <br />