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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <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. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address ZU1 7 & DUMC-ah 0Cd g Cutty Lot Size PM <br /> Owner's Name _l0�n Q � Address )_Z97 A U u o P L 1 n d'«L Phone 0 <br /> Contractor PUMVICe DdIIeIB WIIIng('i_OWdress License No.STV-2-2 Phone —3s <br /> TYPE OF WELL/PUMP: NEW WELL "- WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATIIONX SYSTEM REPAIR LiOTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK &2 SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D�� <br /> ❑ Industrial )II Open Bottom ❑ Manteca Dia. of Well Excavation pia, of Well Casing O <br /> Of Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ST Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal (OII _ Type of Grout <br /> ❑ Irrigation ,Z.?.49 pprox. Depth ❑ Eastern ` Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump Sub. H.P. _ i ` 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 /> 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. ❑ 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 ❑ l <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 /> 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 subiect to workman's compensa- <br /> tion laws of California." <br /> The applic t must call r II qu red inspections. Complete drawing on reverse side. <br /> Signed Title: fl' y —Pry 5,4el Date: <br /> FOR DEPART ENT USE ONLY <br /> Application Accepted by Date v � �Area <br /> � urVA+3�ir.TO / <br /> Pit or Grout Inspection by Date 1( r Final Inspection by - Date ,� <br /> itional Comments: <br /> S466-6781 ❑ Lodi 369-3621 ❑ Manteca BM-7144 F1 Tracy 8355-6385 <br /> Ap licant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT D E AMOUNT REMITTED CASH RECEIVED 13Y DATE PERMIT N0. <br /> � Z <br /> + EH 13-24(REV.1/e 5) S-[34 <br /> - <br /> EH 14-25 �/ I/c SS_�ZNLA3 <br />