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APPLICATION FOR PERMIT <br /> SAN JOAQUIN10CAL HEALTH DISTRICT <br /> 1601 E,AZEL i ON '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 Rules and Regulations of the San Joaquin <br /> Local Health District <br /> Job Address City. Lot Size PM <br /> Owner's Name ��0 Address r� t Phone <br /> Address ,GfJ�iCG4.� License No. Phone Z <br /> Contractor ��_ �� _._ <br /> ` TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> I <br /> PUMP INSTALLATION � SYSTEM REPAIR ❑ OTHER ❑ / <br /> DISTANCE TO NEAREST: SEPTIC TANK 7` SEWER LINES DISPOSAL FLD. PROP. LINE <br /> f <br /> —FOUNDATION AGRICULTURE WELL. OTHER WELL PITS/SUMPS' �5F' <br /> INTENDED DSE " F_.' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i Zindustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Z Dia. of Well Casing <br /> ❑ Domestic/Private ; ❑ Gravel Pack ❑ Tracy Type of Casing C- Specifications 5ra lfli <br /> } ❑ Public _/❑ Qxbeer ❑ Delta Depth of Grout Seal Type of Grout_ZCA? / <br /> El Irrigation �J 1pprox. Depth ❑ Eastern Surface Seal Installed by / <br /> Repair Work Done ❑ Type oPP.Iu/mp . 3'UB H.P. -_, ] State Work Done C>011Well Destruction 171 'Well DlanSeter Sealing Material (top 50') r <br /> F Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Reside nce_ Cpmmercial_ Other V , <br /> Number of living units: Number gf,bedrooms <br /> Character of soil to a depth of 3,eet: Water table depth <br /> SEPTIC TANK ❑ Type/,Mfg �' J Capacity No. Compartments r' <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> DistanL to nearest.,r /Well Foundation Property Line <br /> 4. I LEACH ING,LINE ❑ No. & Length of lines Total length/size <br /> FILTER BEDS rr ❑ Distenee io nearest: Well Foundation Property Line <br /> SEEPAGE PITS, ❑ Depth- :�: Size Number <br /> ' r SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> } DISPOSAL PONDS Q' ' <br /> r� r , <br /> hereby certify tliat/l:have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rifles aridJegulatiane df:th6 San JoaquinILocal.Health District. <br /> Nome owner orlicertsed 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 pers8n J16 such manner as to become subject to workman's compensation laws of.California." Contractors hiring or sub-contracting signature <br /> certifies khe . g:i_I ciirtify that in the performance of the Work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> foHaly <br /> :5 tGnfla�w�-of Calif6rn1ai' 1 <br /> fhe:pppani m r 114equ' ''' ctions. Complete drawing on r se <br /> ' Signed 1 /Title: Date: <br /> ` tJ <br /> OR DEPARTMENT USE ONLY <br /> Area C <br /> 1 Applications r#epfed by Date _ <br /> t o�Grout spection by Date u� i al Inspection by Da <br /> � r Ftes <br /> / , ) <br /> Additional Comments: 1 C r�) �p. <br /> ( ❑'Stl 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE i` INFO OUNT DUE AMOUNT REMITTED C <br /> % CKSH RECEIVED BY DATE PERMIT'NO. <br /> _J <br /> a; + EH 24 1REV. i a s7 S=Q� L <br /> EH 1428 L l 1 <br /> - ci '7—N X .I <br />