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a i , Irk �S <br /> APPLICATION FOR PERMIT <br /> JA <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1� J A 1601 E. HAZEL T ON AVE:, STOCKTON, CA <br /> a <br /> J� <br /> Telephone,(209) 466-6781 _ <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (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 /> made in compliance with San JoaRuin 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. �-.� u-) y <br /> TTT c�`�d !"� M, f <br /> Job AddressCity Lot Size / PM- . <br /> Owner's Name et Address Phone <br /> Contractor-AN&L )JL_J_ `Address [ J�J.�'" icense No.. - Phone. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ° Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by i <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done r <br /> Well Destruction ❑ Well Diameter Sealing Material (top.501) 1 N <br /> Depth Filler Material (Selow;50') 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑' REPAIR/ADDITION ❑ DESTRUCTION eptic system permitted if public sewer is <br /> r available within 200 feet.) <br /> 1 <br /> Installation will serve: Residence_ Commercial Other + <br /> Number of living units: Number of bedrooms �J <br /> Character of soil to a depth of 3 feet: Water table depth U <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 ; ' Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size.q ' r"_F Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ' <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.-3 <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 /> empl y,any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> certifie a following: " certify that in the performance of the work for which this permit is issued, I shalt employ persons subject to workman's compensa- <br /> tion laws California." <br /> The applicant ti s call fo all re ired spec mplate drawing on reverse sid f <br /> � r � <br /> Signed Title: 'y 1 Date: <br /> 1 i <br /> FOR DEPARTMENT USE ONLY / [� <br /> Application Accepted by Date P;Area - <br /> Pit or Grout Inspection b Date Final Inspection by Date <br /> Additional Comments: - <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 °❑ Tracy 835-6385 y <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 .47' <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24{REV.i/a5r <br /> -EH 1426 3� . S>" f I T-.7 <br />