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Yo o1- ow-z4 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA A u 3 <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. TMs 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 �'C City/t-11/1- Size PM <br /> s <br /> Owner's Name ss Phone <br /> (-fi /!/ <br /> • Contractor's Name �enidt-hlo. Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 91­—� SYSTEM REPAIR ❑ OTHER ❑ <br /> 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 AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ lndustrial pen ottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> ❑ Public ❑ Other D Delta Depth of Grout Seal Q T <br /> ype o r t <br /> C] Irrigation --Approx. Depth ❑ astern Surface Seal Installed by <br /> Repair Work bone <br /> 13 Type of Pum . H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') +�!` <br /> Depth- Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> m <br /> Installation will serve: Residence_ Commercial, Other available within 200 feet.) 4`` <br /> Number of living units: Number of bedrooms <br /> s <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK D Type/Mfg Capacity No. Compartments <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 ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 /> 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 California." <br /> The applicant m st ca or all required inspections. Co drawing on reverse side. <br /> Signed � / +���`� Title: <br /> � 7 d�h/e 15 �`� f � - Date: � <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by U1 Date $fir Area <br /> Pit or Grout Inspection by A 0 <br /> q Date L— � ?—Alnal 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 AMOUNT DUE AMOUNT'REMITTED <br /> INFO CA # RECEIVED BY DATE PERMIT"ND. <br /> + EH 14-2a lr3l v. 10/e3i �� <br /> EH 1428 � -1 o <br />