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3se� <br /> APPLICATION FOR PERMIT <br /> . SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> •= �_ -y 1601 E. HAZEL i ON 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 Address4 z�,Xvtz—-10-4 _Z2 4Z6 <br /> Ci lie PM <br /> Owner's Name ._ � - � F14 eak Phone4 3 1 <br /> Contracto�Z_ dress License No. Z hone t0 D 6 <br /> TYPE OF WELL/PUMP: NEOWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 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 /> ❑ Irrigation ---Approx. Depth (71 Eastern Surface Seal Installed by <br /> Repair Work Done C&"'_Type of Pump !rLL4i H.P. State Work Done 0 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') ? <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 clearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify 10mfT_9a­v_e_`pr#p@ked this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and reg ations of the San aquin Local Health District. <br /> Home owne or licensed agent's sig ature certifies a ollowing: " rtify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner to become b' ct w ma s compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies th following: 1 certify t in the cwor or ich this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws f California." <br /> The appli nt mus call equired to draw' g on 6.e;sid <br /> e. <br /> Signed itle: Date: r <br /> F DEPARTMENT USE ONLY <br /> Application Accepted y Date Area <br /> Pit or Grout Inspection by Date Final Inspection b Date <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ 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 95241 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. <br /> + EH 13-24{REV. <br /> EH 1428 <br />