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4 APPLICATION FOR PERMIT <br /> { SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> fi 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM'DATE ISSUED <br /> (Corr plete 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 Addressf � �` '��f�1�tT _ City 5` C�/3 r` Lot Size PM <br /> Owner's Name l�l�i_Gr� �� Address 12J�n 0aklheaW fa, hf � - Phone <br /> ? 'f' ! ( �' l�4 1'I'� � Uf• 8 F'hone ! '�ZD <br /> Contractor r-e d e r 0-, • Address License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> t PUMP INSTALLATION 13SYSTEM REPAIR ❑ OTHER El <br /> DISTANCE TO NEXREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> II INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bolft-iii ,_ _C) Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel3 Pack ; ❑ TracyType of Casing " " _t —" Specifications <br /> ❑'Public ❑ Other# D.-Delta Depth of Grout Seals Type of Grout <br /> ❑ Irrigation J4ppro0-Eastern Surface Seal Installed. <br /> ' by .� C ` Q <br /> I Repair Work Dane ❑ Type of,Pump S ' H.P. -State Work Done <br /> I ._ t[A'I1,G/� I <br /> ! Well Destruction $1' Well Diameter ' ' :Sealing Material (top `) �, <br /> J V ! <br /> Depth FilEer Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 -REPAIR/ADDITION ElDESTRUCTION El (No septic system pePmitted if public sewer is <br /> } }tilt � available within 200 feet.) <br /> I Installation will serve: Residence_ Commercial 1 Other. l\, <br /> Number of living units: NumberVof bedFoorris` ``t <br /> Character of soil to a depth of 3 feet: I �'`"•* Water table depth <br /> SEPTIC TANK ❑ Type/Mfg s Capacity No. Compartment's <br /> PKG. TREATMENT PLT. ❑ { Method of Disposal <br /> Distance-to nearest: Well Foundation Property Line, C <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED 11 Dista nearest: Well Foundation Property-Line <br /> SEEPAGE PITS ❑ Depth J.- Size Number <br /> ( SUMPS El 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 accordarice=with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. ' <br /> r 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 a%to become subject to workman's compensation laws.of California." Contractors hiring or sub-contracting signature <br /> certifies the following:"I certify that I' pections. <br /> rformance of the work for which this permitis'Jsjued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mus c r all required Complete drawing o se;side. p <br /> Signed Title: Date: Z-- 'S S� <br /> ` I FOR DEPARTMENT ENT USE ONLY <br /> Application Accepted by S Date _) 6 a � Area V <br /> k Pit or Grout Inspection by Date Final Inspection by AAe Date <br /> k f <br /> Additional Comments: a ' <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> i <br /> i <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT`NO. <br /> INFO CASH <br /> i 1 <br /> EH 13-24{REV.I/a 5) ` ^ � <br /> EH 1428 1 _ _ T <br /> f <br />