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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> L <br /> ,r 1601 E. HAZETON AVE., STOCKTON, CA <br /> t Telephone Q09) 466-6781 <br /> r I PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> r ' <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 /> ` Job Address EC._ ran City Lot Size�� f}�PM <br /> I <br /> Owner's Name f �f�i � ' __ Address Phone <br /> Contractor ��. �1� I� Cnu St Address S� icense No. 0& <br /> � Phone 7 Mash 1 <br /> TYPE OF WELL/PUMP: ll NEW WELL ❑ r WELL REPLACEMENT 1711 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 PITS/SUMPS C n <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y <br /> �❑ Industrial ❑ 01pen Bottom ❑ Manteca Dia. of Well Excavation! `"" Dia. of Well Casing <br /> t ❑ Domestic/Private ❑ Ghfavel Pack - ❑ Tracy Type-of Casing ; Specifications <br /> ❑ Public ❑ Other 171 Delta Depth-of Grout Seal Type of Grout <br /> i { <br /> I 1 Irrigation h Approx. Depth I I Eastern Surface~Seal Installed by r _ <br /> Repair Work Done ❑ Ty of-Rump- - H.P. 1 tate Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> q TYPE OF SEPTIC WORK: NEW-INSTALLATION l 1 REPAIR/ADDITION I TRUCTION I I INo septic system permitted if public sewer is <br /> ' available within 200 feet.] <br /> Installation will serve: Residence L�Commercial ¢¢ 7�Other t { <br /> Number of living units: J ill Number of bedrooms <br /> Character of soil to a depth of 3 feet: ��B/__ _ r Water table depth <br /> SEPTIC TANK L] Type/Mfg a Capacity No. Compartments <br /> PKG. TREATMENT PLT- ❑ _ _ 1"„_Method of Disposal <br /> l Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE & Length of lines d Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property'Line <br /> SEEPAGE PITS Siie Number <br /> ,h <br /> SUMPS Mance to gt: Well (Foundation Property,Line <br /> DISPOSAL PONDS ❑r Sum <br /> . I hereby certify that I have prepared this application and that the work will be done in accordance with San J aquin county ordinances, state laws, and - <br /> rules and regulations of the{San Joaquin Local Health District. l <br /> Home owner or licensed agent's signature'certifies the following: "1 certify,that in the_performance of the work for which this permit is issued, I shall not <br /> ploy any person in such manner as to become subiect to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> ce ' 'es the followin "I certifythat in the perform_ante of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion Ia of California.' �' ► <br /> The applican �Call �fqit inscti s. mplete drawing on reverse side. <br /> Signe Title: Data: --J 6 <br /> —]FOR DEPARTMENT USE ONLY,..,, <br /> Application Accepted by i Date /lrea Y <br /> Pit or Grout Inspection b II Date Final Inspection by Date / <br /> I Additional Comments: <br /> ` -""❑ StC 466-67f 1 —E] Lodi­369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385•t <br /> e Applicant- Return all copies to: Environmental Health Permit/Services 16011E: :azelton Ave' P.O. Box 2009, Stk., CA 95201 <br /> FFEF 1 INFO AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24[flEY.t i h 5] f� '� �(✓' <br /> EH 14-28 - Z14y�r J <br />