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'1'_ <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 5i# 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> a PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> : pplication is hereby made to the jSan 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/pump and the Rules and Regulations of the San Joaquin <br /> ? + ,; Local Health District. <br /> Job Address. Lot Size PM <br /> I <br /> Owner's Name Addres/4y ., - , Phone <br /> A <br /> � 4Contractor � �d. C Addres � lzLicense Phon� ` <br /> TYPE OF WELL/PUMP: # NEW WELL EJ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMPiINSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ . _ *DISPOSAL FLD: PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL i�ew9! <br /> INTENDED USE TYPE OF WELL I PROBLEM AREA CONSTRUCTION SAF Q*- S t <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Casing <br /> EJ,Domestic/Private ❑ Gravel Pack ❑ Ttar Type of Casing _ ' Specifications- <br /> 1-1 Public , H Other Delta y Depth of Grout Seal Typel of Grout _ <br /> i_w a <br /> I I"Irrigation.. <br /> ""ox. Depth I 1 Eastern Surface°Baal Installed by. <br /> x - <br /> Repair Work Done' ype of Pump H.P. t tit' -x .-•--- Siafe-Work Done _ <br /> Weil Destruc ' ❑' Well Diameter Sealing Material (top 50') <br /> Depth - Filter Material (Below 50') <br /> TYPE OF SEPTIC WORK NEW:INSTALLATION I 1 REPAIR/ADDITION E I DESTRUCTIO No septic system permitted if public sewer is <br /> r�• + I available within 200 feet.I <br /> Installation will serve: "Residence— Commercial Other ! <br /> Number of living-units: Number of bedroomstz <br /> Character of soil"to a depth of 3 feet: f Water table depth <br /> SEPTIC TANK ",w`t❑ Type/Mfg 'Capacity ,No. Compartments <br /> PKG, TREATMENT PLT.❑ •"'Jt •"Method of Disposal. <br /> 9y YDistance to nearest: Wel! Foundation f?roperty.Line <br /> LEACHING LINE ❑ No: & Length of lines Total length/size ^'1 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line �- <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS l-1 Distance to nearest: Well Foundation Property Line V 1 <br /> I DISPOSAL PONDS ❑ 1 �� <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. _r <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 4- <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California.', <br /> �Y <br /> - The applicant ust call for all required inspections. Complete drawing on reverse side. <br /> � f. �. Q��J" <br /> Signa Title. � � �� � Dater <br /> _ `FOR DEPAR MENT USE ONLY <br /> Application Accepted by� Date Area <br /> Pit or Grout Inspection by Date Final �Y v Inspection <br /> Date�� <br /> Additional Comments: tk <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104'' O 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> +"EH 13-24!REV.t i N 51 <br /> EH 14-26 <br /> !� J 7 <br />