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oOfL­.- e,l APPLICATION FOR PERMIT <br /> '""USAN JOAQUIN LOCAL HEALTH DISTRICT -- <br /> z �'' <br /> A,�1 601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone {209) 466-6781 L n <br /> - PERMIT EXPIRES 1 YEAR FROM DATE ISSUED iIrk /I <br /> G <br /> 'IComplete 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. 1851 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address City �� Lot Size �U x �S�M <br /> PhoJ <br /> Owner's Name J Address ne��"'�' - <br /> AV <br /> Contractor Address r T License No. Phone <br /> TYPE OF WELL-/PUMP:, i" , ✓NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ r. <br /> - SYSTEM REPAIR ❑ OTHER ❑ <br /> t 'PUM NSTALLATION=©= :.. .�..�—.�,,...-.- ti {� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE V <br /> R FOUNDATION AGRICULTURE WELL ''OTHER WLL Et PITS/SUMPS �. <br /> —2 <br /> I <br /> + INTENDED USE TYPE OF WELL ' PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industria{ El Open Bottom ❑ Manteca Dia. of Well Excavation _4 Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing `— Specifications <br />' ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> II Eastern Surface Seal Installed by❑ Irrigation ---Approx. Depth <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> k Well Destruction ❑ Well Diameter Sealing Material (top 501 -- <br /> s, Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> r( ailable within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other � a ' <br /> Number of living units: Number of bedrooms .cp <br /> Character of soil to a depth of 3 feet: Water table depth �b <br /> SEPTIC TANK X Type/Mfg &*4KtN Capacity _ _ No. Compartments <br /> PKG. TREATMENT PLT. ❑ <J Method of Disposal <br /> ' s Distance to nearest: Well r Foundation Property Line <br /> LEACHING LINE ❑ No. &7Cength of lines_ Total length/size <br /> FILTER BED ❑ Distance to nearest:~ Well Foundation Property Line <br /> SEEPAGE PITS—D—Depth -Size,�_ Number. <br /> SUMPS ❑ Distance to nearest: Well 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 county ordinances, state laws, and,.21. <br /> rules and regulations of the San Joaquin Local Health District. <br /> I 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 <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 appliaE nt mus# call for all -aqui- ins coons. Complete drawing on reverse side. p� <br /> Signed /yl� Title:_� L,�?'1•d� _, Date: <br /> FOR DEPARTMENT USE ONLY <br /> ► Application Accepted by Date �`a Area v <br /> Pit or Grout Inspectio Date Final Inspection by Date , <br /> �! ♦ , 4. <br /> Additional Comments: <br /> ❑ Stk 466-6781 ElLodi 369-3621 ❑ Manteca 823-71 ❑ Tr cy 835-6385 64^ <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) C RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> f ` <br /> + EH 1&241REv.1/851 ,� �S� � 1 1> � �/5`� $7—.Si <br /> EH 14-26 <br />