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a � <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT NO1 <br /> 1601 E. HAZEL TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete:in Triplicate) � U v_w <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 r3 /s n2© _ City Lot Size PM <br /> Owner's Name Address o Phone <br /> Contract Pei MS-EIL Address JF/d h License N -1 Phone <br /> TYPE OF WELL PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION -SYSTEM'REPAIR ❑ ' Pry <br /> t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE VV <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 <br /> Repair Work Done ❑ Type of Pump f; H.P. , State Work Done <br /> Well Destruction ❑ Well Diameter Sealing.Material(top 509 <br /> Depth Filler Material (Below`501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1 <br /> available within 200 feet.i <br /> Installation will serve: Residence_ Comrn&66i -Other _ <br /> { Number of living units: Number of bedrooms <br /> i <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments. <br /> PKG. TREATMENT PLT. ❑ -+ s . �E�- , Method of Disposal <br /> Distance to nearest: Well `Foundation Property Line,— <br /> LEACHING LINE ❑ No. & Length of lines I Total length/size <br /> FILTER BI=D ❑ Distance to nearest: Well Foundation Property Line <br /> I <br /> i I <br /> SEEPAGE PITS ❑ Depth Size I 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. f <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 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 /> i <br /> The applicant st call for all require inspe ions. Complete drawing on reverse side. <br /> Signed 23 Title: Date: <br /> FORMAXJ�=-�- <br /> RTMENT USE ONLY <br /> Application Accepted by Date r Ly-1 k.w� Area <br /> Pit or Grout Inspection b Date `-Final Inspection by Date <br /> VA_ <br /> Additional Comments: - <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mant 823-7104 ❑ Tracy 83543M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I' FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED �C7ASSH RECEIVED BY �{ 1DATIE( �7 PERMrI)T1NOr.1 <br /> + EH 13.24 IREV.i/e 5t .00 jC,,} ` "l.} '"L [�P t� 1 "'f'i V <br /> t EH 14-26 <br />