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-Se ._, + <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT JY <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> t (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 /> i 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 /> f Job Address ^ .J <br /> N <br /> r .�—Q,i{��C► Lot�e M <br /> S�Gcs �/rT d ��.yv <br />€R Owner's Name= C�-Ot4�eA Address c) Lt2R 4^ Phone <br /> Contractor J Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONS <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 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M <br /> I"1 Public ' ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation rN --Approx. Depth I ] Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done._ t <br /> Well Destructionl<1 Well Diameter Sealing Material (top 50') � L <br /> Depth Filler Material (Below 50') '7 <br /> Imo. TYPE_ OF-SEPTIC.WOR'K: NEW INSTALLATION 11 REPAIR/ADDITION [ I DESTRUCTION i I (No septic system permitted if public sewer is tj <br /> t available within 200 feet.) <br /> Installation Will.serve:, Residence Commercial_1 Other'- <br /> Number <br /> ther.'Number of living,uoits: Number o4 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 ° <br /> 9 Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I i Depth Size Number <br /> SUMPS } �.L� !.Distance to nearest: Well Foundation Proper y Line <br /> , .n . .. t <br /> DISPOSAL PONDS "3 ❑ S 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. f <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;l' <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X _ Title: Date: <br /> FOR DEPARTMENT U E ONLY <br /> Application Accepted by Date / Area <br /> Pit or Grout Inspection by Date— Final Inspection by �~ ate <br /> Additional Comments y� C c <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-&39.1; n, <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 95201 <br /> +P7 I <br /> FEE <br /> INFO r AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> ♦ EH 13241REV.sixsf !�O 5�1 . , <br /> EH 1426 �• 1 +�I R7:; 4319-01 <br />