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�f' • T_ d <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN,LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA n, <br /> 'Tele phone (209) 466-67$1 " <br /> 1.I PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> . (Complete in;Triplicate). <br /> I Application is hereby made tot he 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 ifie San Joaquin <br /> i Local Health District. i - -> tri ° , f° y v¢ <br /> :c,, .::. <br /> Job Address 4q 6 City Lot Size PM <br /> a` <br /> Owner's Name <br /> R1S 51C(� ��ddress "` - Phone 2'`��—� <br /> Contractor Address License No. Phone <br /> • <br /> I TYPE OF WELLIPUMP: I� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INS Ll TION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. `PROP. LINE <br /> FOUNDATION ICULTURE WELL OTHER WELL �AlTSI5UMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CTION SPECIFICATIONS <br /> ❑ Industrial ❑i Open Bottom 17 Manteca Dia.of,Weli�Fzca� Dia. of Well Casing <br /> ❑ Domestic/Private 1-11 Gravel Pack L1 Tracy —Type of Casing Specifications <br /> ❑ Public ❑ Other + ❑ Depth of Grout Seal Type of Grout <br /> Surace.Seal-nstalled by <br /> ❑ Irrigation �pProxEl Eastern i <br /> ' <br /> Repair Work Done ❑ Type ump H.P. j State Work Done <br /> Well Destruction ell Diameter Sealing Material Itop 50 <br /> Depth Filler Material(Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LlREPAIR/ADDITION ❑ DESTRUCT; ION (No septic system permitted if public sewer is <br /> d I y " ':available within 200 feet.] <br /> I Installation will serve: Re�idence Commercial_ Other l �"`� ' M <br /> I Number of living units: i Number of bedrooms i <br /> Water-table-depth <br /> Character of soil to a epih of 3 feet: <br /> I SEPTIC TANK if Type/Mfg Capacity No; Compartments. <br /> PKG. TREATMENT PLT. EII Method of Disposal <br /> r�...�._+ <br /> Distance to nearest: Well Foundation Property Line <br /> r <br /> LEACHING LINE ❑' No. & Length of lines Y Total length/size � "- <br /> I FILTER BED ❑ Distance to nearest: Well Foundation Property Line -� <br /> i <br /> SEEPAGE PITS ❑ Depth Size Number - } <br /> f SUMPS ❑, Distance to nearest:. Well Foundation Property Line <br /> r t . <br /> DISPOSAL PONDS ❑i. , <br /> I hereby certify that I have'6repared 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 certifythatin 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 <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 Californ' .' I�, <br /> T nt m t all fo II required ' �pe tions. Complete drawing on reverse side. -54 <br /> 4 Signed X Title: *^^~¢^ Date: C7�-�} <br /> FOR �ART�MENTUSE ONLY p�'�'7 <br /> I. 3 c� + Area <br /> E Application Accepted by , Date <br /> le <br /> ( ' Pit or Grout Inspection by; Date Final Inspection by/< < Dat <br /> Additional'Comments: <br /> ❑ Stk 466-6781 ❑;Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copi's to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 95201 <br /> FEE <br /> AMOUNTr DUE» AMOUNT REMITTED K H ;' RECEIVED BY DATE PERMIT'N0. <br /> INFO <br /> + EH1324(REV.i/H5) 3 <br /> vu �3S - -/�i� <br /> EH 14-28 -- --- <br />