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APPLICATION FOR PERMIT '�.37y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT D claw <br /> Q 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUEJA195 <br /> N 11 <br /> (Complete in Triplicate) R <br /> �A HEALTH <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install t e 8VOWE.$This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the R n egulations of the San Joaquin <br /> Local Health District. <br /> Job Address,-7 4 1 �r City Lot Size PM p <br /> Owner's Name`` 1 �1 'Address� �,� r Phone f Q <br /> Contractor "3ZZZR� 04e—­j Address6 54. License No/(,3_j23 PhonL11 9 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ 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 /> 11 Public F1 Other Ll Delta-- Depth of Grout Seal Type of Grout _. <br /> Irf'6rigation _.Approx. Depth- - H Eastern Surface Seal Installed by _ <br /> Repair Work Done f3 Type of Pump s-'�J +-Q H.P. cq O State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I N (No septic system permitted if public sewer is }� <br /> i <br /> available within 200 feet.) I" <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 clearest: Well Foundation Property Line <br /> I <br /> LEACHING LINE ❑ No. & Length of lines Total I ngth/size <br /> FILTER BED ❑ Distance to nearest: Well_ Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll 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 <br /> rules and regulations of the San Joaquin Local Health District. <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 /> 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$hall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applican5ust cc 11 for all required inspections. Co plate drawing on reverse side. ) <br /> Signed X f "" v Date: "� 1 <br /> DETMENT USE ONLY Qf� <br /> Application Accepted by Date 7/ <br /> ]/ ` a Area Q <br /> Pit or Grout Inspection by Date Final Inspection by ' /i ` Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ 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 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> +.E1 -241REV.iixs) <br /> EHN144-28 <br />