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+ APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL.HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED COH <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 Ordiriance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health district.y LQT Z F <br /> Job Address f �I/� City 's Lot Size _�. /L ' PM <br /> Owner's Name r I PWCt 0 Address <br /> Phone - <br /> w �wt� !``' Address ) y`� `Zf ` rC� License No. L ZS Phone <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ O�/T/))H77EER-R ❑ ��� <br /> DISTANGE TO.NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. t�'PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIOsf <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatio Dia. of Well Casing�a(� <br /> n <br /> Domestic/Private Gravel Pack racy Type of Casing Specifications <br /> ('1 Public Other 171 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation - --Approx. Depth I i Easter Surface Seal Installed by G— -0r <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Web Destruction ❑ Well Diameter Sealing Material (top 501 <br /> t� Depth Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l 1 DESTRUCTION l I (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. n 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 �c <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> t,�J0 1 hereby certify that l 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 /> "V <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 /> V 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 subject to workman's compensa- <br /> tion laws of California." <br /> ` The applicant m all for a1I requi d ' spections. Complete drawing on r erseesipde. <br /> e-. <br /> Signed Title: <br /> �--L Date: l <br /> r FOR DEPARTMENT USE ONLY <br />� Date "z- .� Area <br /> Applica ' Accepted by -- <br /> Pit ar G11- t�nspection by date f�" mal Inspection by Date <br /> ► Additional Comments: <br /> ❑ Stk 466-6781 ElLodi 369 621 ❑ Manteca 623-71104 ❑ 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 /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO �2JIx CI�j{�] <br /> +.EH13-24(REV.I/H5) C r `!% "V90 <br /> goo ✓�/� <br /> EH 14-26 <br />