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'17 �13 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Tripljcate) <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. IB62 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address City Si <br /> =—f. 69 <br /> 7PM <br /> Owner's Name .� . Address Phone / // <br /> Contractor =ap <br /> Pess_ / License No./ Phone <br /> TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L-1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D <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 /> C1 Industrial f,.! Open Bottom ❑ Manteca Dia. of Wefl Excavation Dia. of Well Casing <br /> [ i Domestic/Private ❑ Gravel Pack 171 Tracy Type of Casing Specifications <br /> I'I Public I I Other I Delta Depth of Grout Seal <br /> Type of <br /> 1 i Irrigation Approx. Depth I 1 E stern Scarf a Seal Installed by _ <br /> Repair Work Dane Type of Pump H.P. { / State Work Dgne <br /> Well Destruction L-, Well Diameter Sealing Material (top 50'} <br /> Depth Filler Material (Below 5M _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIH/ADDITION i I DESTRUCTION I 1 {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: <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Ca acit <br /> P Y No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> 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 Foundation <br /> Property Line <br /> SEEPAGE PITS I I Depth — Size _ — Number <br /> SUMPS I I Distance to nearest: Well Foundation <br /> Property Line <br /> DISPOSAL PONDS Cl <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 <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licen ge 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 pars rn "gel, <br /> r as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the fol win : "!certify at in the Performa f the r ,fo <br /> tion laws of aliforni r which this permit is issued,I shall employ persons subject to workman's compensa- <br /> The applic t must c li all quired i pec' raw- g on (eve <br /> Signed X r <br /> itis: 6��/CL� Date: `f' C1S' <br /> FOR DEPAPTMENT USE ONLY <br /> ! y <br /> Application Accepted by Date �� Area <br /> Pit or Grout Inspection b <br /> y Data Final Inspection by -�� "-'` Date-` t' 'i�X <br /> Additional Comments: <br /> Ll Stk t �=._ <br /> Stk 466-6781 [1 Lodi 369-3621 LJManteca 823-7104 y ❑ Tracy 835-6385 + <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 ; <br /> EEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> + ER 13-24{REV.1 i x b) <br /> EH 14.2e <br />