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J` APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> J 1601 E. HAZELT�ON AVE., STOCKTON CA <br /> Telephone (209) 466-6781 - <br /> PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED <br /> (Complete in Triplicate) <br /> 1 <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 well <br /> /pump/pump and the Ryles and Regulations of the San Joaquin r <br /> Local Health District. _ � ... . ,� <br /> !fi <br /> Job Address - :1 <br /> .,. <br /> f City` � �Lot Size Pj, is <br /> Owner's Name T A 04 4 Address - — - -Phone <br /> Contractor Address_ [ // _ L`idense No Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ;DESTRUCTION ❑ <br /> PUMP INSTALLATION, SYSTEM REPAIR—W1, OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Dl$POS,tL FLD--" PROP. LINE i <br /> FOUNDATION AGRICULTURE WELL _;+ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS— <br /> El Industrial EJ Open Bottom <br /> If Manteca Dia. of Wel! Excavation ���,.f Dia.:of WeIi Casing 1 <br /> Domestic/Private C1Gravel Pack EJTracy Type of Casing j t" S�ecifications'a '{ <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal! y r <br /> El ---Approx. Depth ❑ Eastern Surface Seal Installed by Type of Grout F <br /> f 1 <br /> Repair Work Done Type of Pump s H.P. State Work,Done` <br /> Well Destruction C7, Well..Diameter Sealing Material (top 50') ? <br /> is"- � t g ; <br /> i <br /> b Depth Filler Material (Below 5011) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION 11 (No septic system permitted if public sewer is <br /> avail-able,-within,200 <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms d <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 /> I <br /> LEACHING LINE - ❑ No. & Length of lines t Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation,' Property Line <br /> SEEPAGE PITS ❑ Depth Size t Number <br /> SUMPS ❑ Distance_to nearest; Well Foundation Property Line <br /> DISPOSAL PONDS ❑ +1 <br /> 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. .3y <br /> Home owner or licensed agent's signature certifies the following: '3 certify that in the performance of the work_for which`this-permifis`issued, (shall not <br /> employ any person in such'manner asto become suhject;o;workmen's compensation laws of California."Contractor's hiring or,sub-contracting signature <br /> certifies the following:''`I certify that`ir`the performance of-&work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant t call r all re it d ins ctions. Complete drawing on r erre side. r . <br /> f <br /> Signed Title: { <br /> Date: <br /> ..-s �' • } £FOR DEPARTMENT USE ONLY <br /> Applicatio Accepted by:,-t � 1 <br /> Date 7 Q Area <br /> t S <br /> Pit or Grout Inspection by _ De' Final Inspection b Die <br /> Additional Com'mente <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83.5-6385 <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 C K# RECEIVED BY DATE PERMIT"NO. a <br /> I' <br /> � EH 13241REV.t/551 5-0 5-C <br /> EH 14-26 ! JJJ, <br />