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w <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 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 welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> �'� City • Lot Size PM <br /> Job Address <br /> 1l ��� Phone <br /> I Owner's Name '�A1E1 f� Address <br /> k <br /> Contractor•o- e y MIS-Address �!� �`-�A4 0 _� License No. rJ {D3� Phone Lf k7 3 <br /> i <br /> TYPE OF WELL/PUMP: :. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMPINSTALLATION ❑ A,�" SYSTEM REPAIR ❑ OTHER El <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial � ❑ Open Bottom LJ Manteca Dia. of Weil Excavation Dia. of Wel! Casing <br /> ❑ Domestic/Private EDGravel Pack ❑zTracy Type of Casing Specifications <br /> {� public r "C1"Other """y°"� '� De1Ca ` Depth of Grout Seal <br /> ". „'_.""�.".� "__.. _ Type;of Grout <br /> k I Irrigation '• ---Approx. Depth I 1 Eastern Surface Seal Installed by - <br /> { r H p State Work Done 1 <br /> Repair Work Done .l ❑ Type of Pump <br /> Well Destruction ` ❑ Well Diameter Sealing-MaterialItop"50`)-y "�-7 J` <br /> a Depth Filler Material (Below 50') ' 1 <br /> TYPE OF SEPTIC WORK:" NEW INS I "1 k. <br /> REPAIR/ADDITION I. 1 DESTRUCTION <br /> aNailabpelw thin 200 feet.)permitted if public sewer is <br /> InstaltationWill`serve: Residence' Commercial Othir <br /> Number of living units: Number of bedrooms F < �. <br /> Water table deth <br /> Character"of,4il do'a depth of 3 feet: _ <br /> SEPTIC TANK LIType/Mfg 1 !Capacity No. CompartmOnts <br /> PKG. TREATMENT.PLT. ❑ �. Method of Disphsal <br /> Distance to nearest: Well Foundation r Property Line <br /> s <br /> LEACHIN�PPNE i ❑ No. & Length of lines Total length/size <br /> I FILTER BED f ❑ Distance to nearest: Weil 4 Foundation. ---�T_ Property Line <br /> - y ., .''..i.., ..� <br /> SEEPAGE PITS I i Depth .Size S Number <br /> w,. <br /> SUMPS ; ❑ Distance to nearest:.'" Well G Tounddtidri Property Line <br /> DISPOSAL PONDS` ❑ f� § } <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 JoaquinLocal 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 /> k employ any person in such-manner-as'ioI become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> ' c_ertifies ha following.;"I certify that in the performan f 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 a for all squired ins c i s. Compl to drawing on reverse side. A'. <br /> t � Dater.", <br /> 13�c617 <br /> Signed Title: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by - Date ` 1 Area <br /> I Pit or Grout Inspection Date Final Inspection by <br /> s3 <br /> Additional Comments: � � r L64 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca WJ7104 ❑ 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 I AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> + EH 13241REV. <br /> t/�51 �'i�� � � '� ✓ <br /> EH 14-26 <br />