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�F <br /> O` APPLICATION FOR PERMIT <br />! ��4 SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />' (Complete in Triplicate) <br /> l 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 /> E - <br /> Job Address + <br /> City - Lot Size PM <br /> r Owner's Name Address Phone <br /> Contractor Address License No6� 3 Y3 Phone > ' <br /> TYPE OF WELL/PUMP_1 NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE <br /> ter__ <br /> - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia: of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack', ,❑.Tracy Type of Casing Specifications <br /> 1`1 Public M Other ll'Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation --Approx. Depth I I Eastern -Surface Sea! Installed by <br /> r,c - <br /> Repair Work Done ❑ Type of Pump H.P. I State Work Done_ <br /> Well Destruction ._❑ Well Diameter Sealing Materia!(top 50') <br /> Depth < ° Filler Material (Below 50 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I,'1 RFPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is <br /> ' available within 200 feet.)' <br /> r <br /> Installation will serve: ResidenceCommercial— Other y <br /> Number of living units: Number of b d ams h�,� , <br /> 14- <br /> Character of soil to a depth of 3 feet: 'V Water table depth <br /> SEPTIC TANK ❑ Type/Mfg. - Capacity }No. Compartments <br /> PKG. TREATMENT PLT. ❑ 4, f "' <br /> .a <br /> �.,.. * Method of Disposal <br /> 'Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE be No. & Length of lines Total length/size . <br /> FILTER BED ElDistance to nearest: Well r` Foundation_s* Property Line <br /> SEEPAGE PITS {�DepthsSize <br /> Number - - <br /> SUMPS L] Distance to nearest: +„Well .1t -- ,FounBafion L�' .,,= property Line -� <br /> DISPOSAL PONDS ❑ f i <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 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all squired"tions, Complete drawing on reverse si ' . <br /> Signed X T ' Title: Date: <br /> 0 _ FOR DEPARTMENT USE ONLY f� <br /> Application Accepted bAV— V Date C� Area ! <br /> "` W.�L� <br /> Pit or Grout Inspection Date Final Inspection by Date 0 y <br /> r _ JJ �r <br /> Additional Comments: �i1A� t „ _ O .. S E p 4- L, -- <br /> ❑ Stk 466-6781 17 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ' <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I <br /> FEE <br /> CK <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> a EH 13-24 IREV.r/M51 <br /> EH14-ZeII���C—q 'EM -1-7 <br />