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4 _ APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1 V" (Complete in Triplicate) <br /> i <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal[the work herein described.This application is i <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 /> Job Address " City -1,eyCr l Lot Size90 PM <br /> Owner's Name Oeo0 / iGJ -LS Address af3Zl � Pry ��� Phone <br /> Contractor Address ZZZ /' 11UF License No. _Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Or— r <br /> PUMP INSTALLATION ;k - 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 6 �t <br /> ❑ Industrial - ❑ Open Bottom (_1 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 7F Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout---. "V�+ <br /> I I Irrigation _.-Approx. Depth 1.) Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump - H.P. _ �� State Work Done <br /> Well Destruction Er//�Well Diameter Sealing Material [top 50') - `t <br /> — Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1-1 REPAIR/ADDITION I I DESTRUCTION I. I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial _ Other <br /> Number of living units: Number of bedrooms N <br /> Character of soil to a depth of 3'fee : Water table depth <br /> r <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest:, Well _7��: dation Property.Line <br /> LEACHING LINE ❑ No. & Length of lines �otal length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> i 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 Ca'fornia." <br /> The applican ust call for all require nspections. Complete drawing on reverse side. <br /> E <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date A .Area !1, <br /> Pit or Grout Inspection by Date Final Inspection bye-Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 REMITTEDRECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> • EH 13.24 Ittev.i/n 513 L <br /> EH 14-28 <br />