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APPLICATION FOR PERMIT ; <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Pi <br /> Telephone (209) 466-6781 <br /> �� � e'P°'-1 `� PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDf <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 welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address � 1 1 V 14 , e-LD e- ke- ity a;�> L ze PM <br /> Owner's NameYflf 19�l� r P, kk-a�EA! ,2;ress 9" �+-'�- �/ Phone <br /> Contractook, -T.-C, Address (Q ,11� 6 -eLicense No.R)'20gY;D Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION D SYSTEM REPAIR .EY OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL FLD. r PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL___L_ PITS/SUMPS <br /> INTENDED USE •TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca o---Dia. of Well Excavation Dia. of Well Casing <br /> 1�5Domestic/Private ❑ Gravel Pack ❑ Tracy f_Type of Casing f Specifications <br /> M Public Cl Other f_] Delta '-Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I 1 Eastern Surf a Seal Installed by <br /> Repair Work Done +$ Type of Pump H.P. °Z_ State Work Done L V 1 <br /> Well Destruction ❑ Well Diameter ,Sealing.Material Itop 501 <br /> Depth Filler Material {Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.'] REPAIR/ADDITION i I DESTRU_CTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other, r <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 /> I <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 signatu <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 compen - f <br /> tion laws of California." <br /> .j <br /> The applic s call for a�requiredction . Comp to drawing on rev side. � <br /> Signed X c Title: �[�S Date: <br /> F £PARTfNENT USE ONLY <br /> I Application Accepted by Date ' � Area <br /> Pit or Grout Inspection by Date Final Inspection by Date 7 <br /> Additional Comments: <br /> i ❑ 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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASHI CK RECEIVED BY DATE PERMIT'NO. <br /> r. <br /> EH 3-24 IREV. <br /> EI-11114-26 i <br /> t <br />