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� �~ APPLICATION FOR PERMIT s <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE; TON AVE., STOCKTON, CA <br /> Telephone (209) 486-6781 <br /> P IV EXPIRES 1'YEAR FROM DATE ISSUED <br /> �NV�Ftam�N5RVICES (Complete in Triplicate) <br /> Application is hereby ma;:iiABan 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 /> I <br /> Job Address L21} . GC�, City Lot Size PM <br /> Owner's Name Ja Z, A�l Address114 /2-- Phone <br /> Contractor �/ Address . cense No. 9_ V Phone <br /> I <br /> TYPE OF WELL/PUMP: NEW WELL — / WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> = PUMP INSTAL TI f� SYSTEM RE IR ❑ OT ER_❑.u:— j <br /> DISTANCE TO NEAREST:.SEPTIC TANK/ � SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL j2 PITS/SUMPS <br /> INTENDED USE TYP OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO /j <br /> ❑ Industrial pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑-Domestic/Private � . ❑ Gravel Pack ❑ Tracy Type of Casing cifications <br /> ❑ Public f 1 Other Cl Delta Depth of Grout Seal Type o Grout <br /> I nyatian <br /> --Approx. Depth 1,1 Eastern Surface Seal Installed by <br /> , <br /> Repair Work Done ❑ Type of Pump . H.P. �� State Work Dories <br /> I ipil Pestruction ❑,�Well'DiameterIds Sealing Material (top 50') ° <br /> *; Depth Filler Material (Below 50') " <br /> = TYPE OF SEPTIC WORK: NEW INSTALLATION [.'I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is <br /> 1t i available within 200 feet.) Y y' <br /> Installation will serve: Residence ,Commercial_ Other IN <br /> Number of living units: Number of bedrooms i <br /> Character of soil to a depth of 3 feet: t Water table depth <br /> SEPTIC TANK a ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal .� <br /> 3 - <br /> tz Distance to nearest: Well Foundation Property Line <br /> a% A <br /> CEACHiNG�LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> 'SEEPAGE PITS 1 1 Depth! r ' Size Number - <br /> SUMPS ❑ Distance to n4al`4t: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ fi <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 j <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." r <br /> The applicant t call for all r quired inactions Complete drawing on r erse side /�.—�� f <br /> V Cy <br /> 9 :Lr[ `� Date: <br /> Signed X Title: r <br /> O DEAARTIVIENT USE ONLY <br /> Application Accepted by0_7Date -/7Are <br /> I <br /> i <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk..-468-6781 ❑ Lodi 369-3621'r ": ❑ Marn"e'ca ,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 /> a t I <br /> � ) FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY___ „DATE PERMIT NO. <br /> PO CASH <br /> ♦ EH 13-24 <br /> EH 14.26 v <br />