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APPLICATION FOR PERMIT <br /> 9, <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> WQ4 ! PERMIT EXPIRES TYEAR 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 6" <br /> City C I Lot Size GcCiCt' <br /> PM <br /> Owner's Name _/ r -LCI .,. X24 _— Address ^ `�i•. �cj imek Phone _a <br /> Contractor i Address <br /> " License No Phone <br /> TYPE OF WELL/PUMP: NEW WELL � WELL REPLACEMENT ❑ DESTRUCTION Ll <br /> PUMP INSTALLATION Lam, w -SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISP_OSAL..FLD.Z�S� PROP. LINE '30 r \ I <br /> FOUNDATION -AGRICULTURE WELL OTHER,WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA$ x " <br /> CONSTRUCTION SPECIFICATIONS <br /> D Industrial" J ppen Bottom ❑ Manteca--I pia. of Well Excavation_! - Dia. of Well Casing ^'r <br /> ' Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> Specifications <br /> M 1 Public f 1 Other ❑ Delta `` <br /> a Depth of Grout.5eaf , ��"� <br /> LI a��t � e' Type f Grout C-�:���"` <br /> ! I Irrigation � � T 0_Approx. Depth l I Eastern �`' `[ <br /> Surface Seal installed by (�f£ <br /> Repair Work Done L7 Type of Pump State Work Dane <br /> : .Lz 7 H.P. t F f� <br /> Well Destruction ❑'-1 elI Diameter Sealing Material (top 50') <br /> i r Depth J Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 17 REPAIRlAOD1710N I ] DESTRUCTION I I (No septic system petr(nitted if public sewer is <br /> available within 20.0 feet.). <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units: Number of bedrooms t <br /> r 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 /> tea ) Distance to nearest: Well -Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> '"SUMPS L1 stance to nearest: Well <br /> *y Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin countt <br /> rules and regulations of the San Joaquin Local Health District. y ordinances, state laws, and <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 /> Cemploy any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature 1 <br /> ertifies 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 must call for all required inspections. Complete drawing on reverse side. <br /> Signed Title: L" <br /> TTr Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application.Acce ted_b. _ QA_ <br /> a p y a ..Date <br /> Pit or rot Inspection b ! Date�2� Final Inspection by lliL/ Dater t <br /> Additional Comments: <br /> :❑ Sik 466-6781 ❑ Lodi 369-3621 0 Manteca 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 <br /> FEE AMOUNT DUE AJh0UNT REMITTED CK <br /> kr ' <br /> 1 .. <br /> +.EH 13.24IREV,tixW (/f'Yu�,J S <br />