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it 1 <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 1 YEAR FROM.DATE,ISSUED <br /> (Complete in Triplicate) ... 10,w. ` <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. 1861 f welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. /f Q. .=- <br /> Job Add F g ' 'K• � "� �"�`"" t Lot Size PM <br /> t - " <br /> Owner's Nai�.�A13 -r 1� w`Addres5 ' Phone <br /> t ( rt <br /> Contract SLS"r� 1'" �{1Z- Address CPQ vl(?�Pl � A License NoAI42AG74 Phone ;J_.2C1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION � SYSTEM REPAIR ❑ OTHER ❑ <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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> L-11omestic/Private ❑ Gravel Pack EI Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> 5p rtigation --Approx. D El Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump� $_ H.P. 14:;� State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <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_-- Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ��' ❑ Type/Mfg Capacity No. Compartments <br /> PKG.'TREATMENT PLT. ❑ 1 r' Method of Disposal <br /> ` / ,,; Distance to nearest: . Well Foundation Property Line <br /> f <br /> LEACHING LINE -,-No. & Length of lines Total length/size <br /> FILTER BED F❑ Distance to nearest: Well Foundation Property Line <br /> f J.� <br /> SEEPAGE PITS ❑ Depth"- - Size Number <br /> 4 <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br />'! DISPOSAL"PONDS ❑ � <br /> 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 regulation's 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&follinrtify that in the performance of a work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion lawThe app4t� <br /> in . Co late drawing on e side. <br /> Signed Title: Dat - <br /> #. FOR DEPARTMENT USE ONLY _ J <br /> P b <br /> Application Accepted by C f4 Pate MO'—«� Area <br /> Pit or Groutspection by Date Final Inspection by �� ( Date L /4 <br /> Additional Comments: <br /> Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> plicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r <br /> ',-FEE gMOUNT DUE AMOUNT REMITTED� CASH RECEIVED BY DATE PERMIT N0. <br /> INFO t <br /> - <br /> + EH 13-241REV.1/851 <br /> EH 14-26 <br />