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S <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT w <br /> 1601 E. HAZELTON 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 a ` �' NQS !, City Lot Size PM <br /> 41 <br /> Owner's Name r^'�� �� -� � � Address l (v. IT-AePhone $ <br /> 571 <br /> Contractor Address / . License No. o[9mo—Phone . <br /> TYPE OF WELL/PUMP: V NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK /00 " SEWER LINES DISPOSAL FLD. /,04 ' PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION$ p <br /> 11 Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private A Gravel Pack X Tracy Type of Casing pvd Specifications , <br /> LD Public ❑ Other ❑ Delta Depth of Grout Seal 1w, :7� ,Typeof rout <br /> E] Irrigation _,Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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. ❑ 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 Found5tion Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> f 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."Contractors hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- <br /> tion laws of California." ' <br /> The applicant u call for all required",' pections. C mplete drawing on reverse side. <br /> Signed Title: Date: <br /> a­'DateSZ4 <br /> DEPARENT USE ONLY /�/'Application Accepted Date Jtf9l _ Area t/Pit or Grout Inspectio y Finaalll Inspection by Date <br /> Additional Comments: 41 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 If Manteca 823-7104 Tracy 835-638.5 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 Aazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE I AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> + EH 13-24(REV.1/e5) �d� "� IWIq7q] <br /> EH 14"26 <br />