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F <br /> APPLICATION FOR PERMIT I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT NO L <br /> 1601 E. HAZELTON AVE., STOCKTON, CA c7 V, <br /> ' Telephone {209} 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 'C`I .d <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 <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}Z �J� City_ Lot Size PM <br /> Owner's Name" �t,� � Address Y{ P one � 9 9C� J--,d <br /> Contractor _ /L Address License 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 /> ❑ Ind6strial1 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> rt � <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 � F <br /> Repair Work Done ❑ 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 /> Available within 200 feet.) <br /> Installation will serve: Residence_ lCommeC 17 Other <br /> f <br /> FFF <br /> Number of living units: Number of bedrooms /� <br /> Character of soil to.a depth of 3 feet: ! ° ` 1---Water table depth f0 <br /> SEPTIC TANK ❑ Type/Mfg ;.II Capacity ? No. Compartments / <br /> PKG. TREATMENT PLT. ❑ I} Method of Disposal <br /> I t <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Weil FoundationProperty Line <br /> SEEPAGE PITS ❑ Depth -Sizert Number <br /> SUMPS t ❑ Distance to nearest: Well Foundation i Property Line <br /> DISPOSAL PONDS ❑ H 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 Heaithi bisfrict. � ' ° is j <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 j <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting 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 Calif ia." 1 j <br /> The applicant call for all a uired inspections. Complete drawing on reverse side. k? 1 <br /> K Signed Gam7 Title:. Date:�f7� -�� <br /> (FOR ARTMENT USE ONLY F=, <br /> _ dk <br /> Application Accepted by n _! L Date..-' <br /> Area <br /> i <br /> Pit or Grout Inspection by F Date Final inspectioq by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ Manteca 823-7104 EJ Tracy 835- <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 <br /> AMOUNT DUET AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> -+ EH13-24(REV.tir351 <br /> EH 14-20 <br />