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' APPLICATION FOR PERMIT <br /> .. <br /> SAN JOAaU1N LOCAL HEALTH DISTRICT <br /> 3 1601 ,E. HAZE(.TON AVE., STOCKTON, CA <br /> 'Telephone (209)-466-6781 <br /> I <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED V` � Z `? <br /> (Complete in Triplicate) HEALTH <br /> ! Application is hereby made to the San Joaquin Local Health District foraNvtil�(] ln �A VS(,1<S <br /> f made in compliance with San Joaquin County Ordinance No:549 for sewage or No. 1862 for well/rmit to construct dpump and the Rules an/or install the work d Regula a IrcJoaq n <br /> Local Health District. Joaquin <br /> Job Address <br /> . w• City Y� L Lot Size <br /> PM <br /> Owner's Name _ �'�? - /;q C/ 7/ <br /> Address u I Phone <br /> Contractor 4 4l. i -1f Address <br /> License Na.��phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT <br /> DESTRUCTION LiPUNfP INSTALLATI SYSTEM RFPAiR Q T. THER ❑ �5� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ` <br /> DISPOSAL FLD.-._ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL" ;L,' p *'OTHER WELLp1 <br /> -PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA I S <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatio y <br /> Dia. of Well Casing <br /> Domestic/Private XGravel Pack IXTracy Type of Casing i h <br /> ❑ Public 11 Ot er /Specifications I fJ <br /> ❑ Delta Depth of Grout Seal <br /> El Irrigation I�_A Type of Grout M <br /> pprox, Depth ❑ Eastern Surface Seal Installed by � 1 <br /> Repair Work Done ❑ Type of Pump H.P. <br /> State Work Done 00 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') Gil <br /> Depth Filler Material (Below 50') j <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> + available within 200 feet.) l <br /> Installation will serve: Residence� Commercial_ Other <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 Ca act <br /> p t1' No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal }tr <br /> Distance to nearest: Well Foundation (vl.J <br /> Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well <br /> Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size <br /> Number <br /> ,❑ Distance to:nearest.:, . Well Foundation - <br /> DISPOSAL PONDS' ' L] Property <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 fallowing: "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 st call for II rQq ire inspections. Complete drawing on rev me side. <br /> Signed v Title: Date: <br /> FOR ARTMENT USE ONLY <br /> Application Accepted by �} P Date <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> ., Date <br /> Additional Comments ati - <br /> ❑ Stk 466-6781 ❑ Lodi' 369-3621 ❑ Manteca 823-7104 O Tra 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> t FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT NO. <br /> + EH 24IREV.t/a51 <br /> W •�� � .{J � ! '��� <br /> EH 74-26 - <br />