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3 <br /> APPLICATION FOR PERMIT <br /> ` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the br"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. M <br /> r y <br /> I Job Address Cit Lot SizerxM Z-75_ PMfff <br /> Owner's Name Addressjt � , 9f� / Phone <br /> i t w <br /> 1 �'f Address r <br /> No.Contract tPhone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> { PUMP INSTALLATION ❑ SYSTEM-REPAIR ❑ OTHER ❑ z <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SAL FLD. . PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> t INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS 1 <br /> ❑ Industrial ❑ Open Bottom ❑ Mant Dia. of Well Excavation Dia. of Well Casing <br /> t ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications <br /> 1-1 Public <br /> 171 Other la Delta Depth of Grout Seal ;° Type of Grout <br /> I I Irrigation -A x. Qepth I Eastern Surface Seal Installed by . <br /> r Repair Work Done ❑ e of Pump H.P. State Work Done_ <br /> Well Destruction Well Diameter Sealing Material Itop 50') <br /> Depth Filler Material (Below'50') <br /> TYPE Of SEPTIC WORK: *NEW INSTALLATION I.] RrPAIR/ADDITION i I DESTRUCTION 11 INo septic system permitted if public sewer is <br /> available within 200 feet.) C <br /> Installation'will serve: Residence Commercial -Other- <br /> Number of living units: Number of bedrooms rf <br /> Character ofsail to a depth of"3 feet: Water table depth <br /> k SEPTIC TANKType/Mfg Capacity f No. Compartments <br /> PKG. TREATMENT PLT. ❑ 'Method of Disposal " 1 <br /> 1 � <br /> Distance to nearest: Well Foundation Proi5erty'Line Z s <br /> LEACHING LINE 15V�No. & Length of lines 3 40 /a67 Total length/size ifa <br /> FILTER BED ❑ Distance to nearest: Well I Oh Foundations Property Line SO kt <br /> SEEPAGE PITS I'] Depth Size ![3 _ Number <br /> SUMPS Distance to nearest: Well 14002 Foundation_- 4 4 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 /> h q 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 whieWthis permit is issued, I shall employ persons subject to workman's compensa- <br /> tion.laws of California." <br /> i <br /> The applicant call for all req ' d ' spections. Complete drawing on reverse side. <br /> I <br /> Signed X Title: Date: , <br /> FOR DEPAF14TMENT USE ONLY <br /> ApplicatioAccepted by�" /7 �[� Date j Area <br /> Pit or o s e on byfi1� ///r1F��/ ate ��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 /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> + EH 13-24 <br /> EH 14-26 <br /> lFiEV.iin51 �.�. -7b �A <br /> r 4 <br />