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� 4 <br /> APPLICATION FOR PERMIT Al <br /> /r SAN JOAO.UIN LOCAL HEALTH DISTRICT <br /> .�-a. 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> y l Telephone (209) 466-6781 t4 <br /> j.-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/pu and theRules and Regulations of the San Joaquin <br /> Local Health District. > <br /> Job Address ` City of Si e— PM <br /> M Owner's Name Address Phone iI <br /> Contractor's Name License No. C v f �Pfione ✓ I � <br /> TYPE OF WELL/PV P: NEW WELY ❑ WELL REPLACEMENT 9, DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REkR Li OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES{ v�' "= DISPOSAL FLD. PROP. LINE <br /> FOUNDATION i AGRICULTURE WELL OTHER WELL l PITS/SUMPS <br /> INTENDED USE TYPE OF WELL'S { PROBLEM AREA /CONSTRUCTION SPECIFICATIONS t <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.of4Well Excavation Dia. of Well Casing , <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type-of Casing Spec4cations ` <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout'Seai Type of Groui�-_ ~� <br /> r ❑ Irrigation ---Approx. Depth ❑ Eastern Sun`ce Seal Install d'by, <br /> Repair Work Done ❑ Type of Pump H.P. f StaLe,Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 ` { <br /> '. <br /> Depth /'Filler Material [Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR `DDITION Ll DESTRUCTION C].(No septic system permitted if public sewer is <br /> ..`` 't' ' lavallable within 200 feet.) <br /> Installation will serve: Residence_ Commercial? Other <br /> Number of living units: Number of bedrodms e <br /> Character of soil to a depth of 3 feet: f _Water table depth <br /> SEPTIC TANK ❑ Type/Mfg i Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ !f / Method of Disposal__ i <br /> Distance to nearest: Well 6ndation Property Line , <br /> J <br /> �4 S <br /> LEACHING LINE ❑ No. & Length of linesTotal length/size ' 1 <br /> FILTER BED ❑ Distance to nearest: Well undation Property Line E y ----�— <br /> S PAGE PITS ❑ Dept Number <br /> 1 <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> OSALPONDS ❑ i <br /> hereby certify that I have prepared this application and that the work will be done in accordance with Sart 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 1 <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 applicant must call for ail re d Inspections. Complete drawing on reverse side. <br /> „ <br /> Signed X Title: w._ ,... w.."�, Date: .w _ ... _ _ _.;.. <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ` Date Area <br /> Pit or Grout Inspection by Date " Final Inspection bye Date <br /> Additionat 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 RECEIVED BY DATE PERMIT"N0. <br /> INFO CASH p� I <br /> + EH 13 -7-)7 -n 24 4REV.10183) V7O I M <br /> EH 1425 -J <br />