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0 <br /> ,E <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> aquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> Application is heiehy made to the San Jo <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 Joaquin41 <br /> Local Health District. + r14 G <br /> City G Lot Size <br /> Ilk <br /> I Job Address <br /> Phone <br /> Owner's Name r S 4 SAldress <br /> Contractor 1 u `� Address <br /> License Na. �-Phone���7,114 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> l 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 A EA-` -CONSTRUCTION SPECIFICATIONS <br /> 5 Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> ;D DomesticlPrivate ❑ Gravel Pack ❑ITracy Type of Casing <br /> Il Public ' <br /> ❑ Other F1 Delta Depth of Grout Seal Type of Grout <br /> I ! Irrigation .Approx. Depth <br /> 11 Eastern =Surface-Seal.lnstalled-by <br /> - <br /> ' •Re}air Work Done' ❑ Type of Pump H.P: State Work Done_ <br /> Sealing Material Itop 50'1 -- <br /> Well Destruction r� ❑ Well Diameter g <br /> I ' Depth Filler Material (Belo 50T <br /> j TYPE OF SEPTIC WORK: NEW INSTALLATION {l REPAIR lADDITION DESTRUCTION I i (No septic system permitted if public sewer,is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: I Number of bedrooms 13 <br /> k Water table depth <br /> Character of soil to a depth of 3 feet: <br /> a' <br /> SEPTIC TANK ❑ Type/Mfg - Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> I 4 Distance:to nearest: Well Foundation Property Line <br /> c <br /> ` LEACHING LINE V"—No.,& Length of lines tab Total length/size <br /> i FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> d ; <br /> J Size Number <br /> SEEPAGE PITS I1.r.,Depth <br /> -SUMPS [_1'?' Distance to nearest: Well Foundation. Property Line <br /> DISPOSAL PONDS_,"t-,f - <br /> hereby certify chat 1 Nae prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of'the'San Joaquin Local Health District. <br /> : "I certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following <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 /> The applicant must call f`al(requir insp ctions. Complete drawing on reverse side. <br /> Signed X <br /> I Title: �� Date: <br /> �FORR DEPARTMENT USE ONLY " <br /> Application Accepted by r"' —' ""- Date Arear C� <br /> � �-som <br /> Pit or Grout Inspection by Final Inspection by ata <br /> i Additional Comments: J <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 /> s <br /> I FEE �...��_ —_ <br /> INFO -CK <br /> I AMOUNT-DUE AMOU- NT REMIftEt) RECEIVED BY DATE <br /> PERMIT'NO. <br /> ♦.EH 13-24 IREV. <br /> r <br /> 04 14-26 VVV <br />