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�3 <br /> _ - APPLICATION FOR PERMIT i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT t ' <br /> 1601 E. HAZE I ON AVE.; STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. <br /> i� (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 Joaquin County Ordinance No.549 for sewage or"No. 1852 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. y. 4 <br /> Job Address City72:,!S� Lot SizePM <br /> Owner's Namej/',� Gddress <br /> r� J <br /> Contractor, ��/Z � Addressy_ / d=5 5;?.!5 CL License No. Phone k <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El = <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 Packs ❑ Tracy Type of Casing Specifications V [ <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by W <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done d <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 ❑ INo septic system permitted if public sewer is ^ <br /> available within 200 feet.} <br /> Installation will serve: Residence_.Commercial Others <br /> Number of living:units3. I Number,of bedrooms- <br /> Character of soil to a depth of 3 feet: Water table depth R� <br /> SEPTIC TANK ❑ Type/Mfg Fj Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ i, Method of Disposal <br /> r {. <br /> Distance to nearest: Well Foundation Property Line <br /> _ I <br /> LEACHING LINE ❑ No. & Length of lines i "-Notal length/size <br /> FILTER BED ❑ Distance to nearest: Well ' Foundation Property Line <br /> r r <br /> t <br /> SEEPAGE PITS ❑ Depth I Size A �- � `> Number <br /> SUMPS ❑ Distance to nearest: Well Foundation z�t Property Line <br /> DISPOSAL PONDS ❑ as " <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 following: ' 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 subcontracting 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 /> 1 I <br /> The applicanust IIorequiredins ctions. Complete drawing on reverse side. <br /> Signed X <br /> .� Title: e7_7A,_� Date: <br /> FOR DEPARTMENT USE ONLY <br /> t �°� <br /> Application Accepted by Date Y 00 Area ff <br /> y { <br /> Pit or Grout Inspection by 1 / Date. Final Inspection by p Date ` Q' <br /> Add-ionaI Co ments: C4-'.0l l e l W rl� •=a '" crJ�. — C�i /\ <br /> -- tk A _466-6781 , ❑,Lodi r 369 1 -.t q Mant ca 823-7104 1` , .❑ Tracy '835-6* <br /> Ap licant Return all copies 4o: Environmental,Health Permit/Services 1601,E.Hazelton Ave., P.O. Box 2009, Stk., CA 955201 f <br /> Six <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT`'NO. <br /> + EH 14.25(REV.t/951 c �w �� -Sy <br /> V <br />