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APPLICATION-FOR:PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I 1601 E. HAZE I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . <br /> 1 (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 d <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for Nell pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Dq <br />+ Jab Address City Lat Size . PM <br /> Owner-'s Name � / / �� /V Address / - +� ���!Y/I A Phone 93 <br /> a 26 ' [ <br /> 4 ` r « <br /> t <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 3 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 /> i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing _ Specifications VV <br /> ❑ Public ❑ Other , ❑ Delta Depth of Grout Seal Type of Grout /y <br /> j El }Irrigation i �4pprox. Depth ❑ Eastern Surface Seal Installed by V1 <br /> i <br /> Repair Work Done Ll 'Type of Pump H.P._ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 -? <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> r available.within 200 feet.) <br /> Installation will serve: Residence Commercial Other/tet r <br /> Number of living units: J, Number of bedrooms <br /> Character,of soil to a depth of 3 feet:. ' `d� Water table depth <br /> SC EPTIC T <br /> ,Type/Mfg µ =Aie Capacity '2O a No. Compartments �Z_ <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> ,� <br /> i Distance to nearest: Well, Foundation Property Line 1d <br /> LEACHING LINE No. &'Length of lines 1� Tptat length/size U <br /> FILTER BED ❑ Distance to nearest: 'Well Foundation / Property Line j©� <br /> SEEPAGE PITS r - ❑ DeptFi f.t i a,Size / / umber r• / <br />` SUMPS 1 �DistanceNto nearest: Well` _O Foundation Property Line-0V�� <br /> DISPOSAL PONDS ❑.-. . r�,..C *,I Jt I -y F - [0-1 1� <br /> I hereby certify that I hai/e 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 ( i <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 1016,705g_71 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 iflust call for all rwired inspections. Complete drawing on reverse side. �7 / <br /> Signed X Title. Date: i5 1 <br /> r FOR DEPARTM NT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date l-_Z_74�- i <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835.6385 <br /> Applicant- Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT/DUE AMOUNT REMITTED �7CASH RECEIVED BY DATE PERMIIT"N0. <br /> + EH 13-24(REV.-10/83) (� (y{ �,.� $Z-�-'J 0-7� ' <br /> EH W28 J <br />