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r ! <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin j <br /> Local Health District. f <br /> Job Address e33 �ac,/I �, - City - Lot Size [PM <br /> Owner's Name / j � D&V 1VV Address r `� Phone �-2c <br /> i j Q <br /> Contractor's Name `:Y t/ �I�� ��► License No. 14 .99 Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> f t PUMP:INSTALLATION +❑ ,t SYSTEM.REPAIR ❑ OTHER ❑ <br /> DISTANCE T.0 NEAREST: SEPTIC TANK SEWER LINES c�� `f DISPOSAL FLD.1 PROP. LINE <br /> FOUNDATION 1 _ `�- AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f <br /> t❑ Industrial ❑ Open Bortbrri. Manteca Dia. of Well Excavation Dia. of Well Casing <br /> JK Domestic-/Private X Gravel Pack`"" - 17 Tracy s L Type of Casing G Specifications <br /> ❑ Public — ❑ Other ❑ Delta- Depth-of Grout Seal .' r Type of Grout <br /> El Irrigation � __-.�lpprox. Depth Ea Surface'Seal`,Installed by'"•-' <br /> Repair Work Done • 171—'Typ�of'Pump H.P: State-Work-Done—" <br /> WeII Destruction ❑ Well Diameter.. 5} ,F <br /> Depth I Filler Material {Below 501 <br /> rTYPE OF:SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is =y <br /> d} available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living Units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: I Water table depth+ <br /> + <br /> SEPTIC TANK ❑f-Type/Mfg + Capacity No. Compartments <br /> PKG. TREATMENT.PLT. ❑ _ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line i <br /> LEACHING LINE ❑ -No. & Length of lines Total length/size ^3 <br /> FILTER BED El Distance to nearest: Well Foundation Property Line ' <br /> SEEPAGE PITS ❑ ;Depth Size Number } <br /> SUMPS ❑ :Distance to nearest: WellT i '}Foundation-.-,r- -.,r. Property Line ' <br /> DISPOSAL PONDSj� y f❑ <br /> I hereby dertify that'I have prlkpdred this application and that the work will be done in accordance witYi San Joaquin county ordinances, state laws, and <br /> rules and?regulations of the San Joaquin Local Health District. I I I <br /> Home owner or licensed agent's signature certifies the following: "I-ee+tify-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 fdr which this permit is issued, I shall-employ-persons subject to workman's compensa- <br /> tion laws'of California." u <br /> The applicant m st'rc�-a'-'lllf�f'�or all required insZotions, Complete drawing on reverse side. <br /> Signed �t` ` 'r7'� L.rrty[a»� "'� Title: �i r►rz J� Date: <br /> i FOR DEPARTMENT'U8E ONLY <br /> est <br /> Application Accepted by I - Date —2-- -=1•'S ± Area JW 010 <br /> i <br /> Pit or Grout Inspection-bye — ---Date--—Final Inspection-by— - Date <br /> Additional Comments: Biu ' Go e,4<4vSYu✓lOh Cf�LO_��1 __— <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621: ❑ Manteca 823-7.104 ��Tracy*,835-6385�4 ,' <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601-E.Hazelton Ave., P-O?Box 2009, Stk., CA 95201 <br /> A, :\ { <br /> +R e <br /> FEE AMOU T DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMIT:NO.' <br /> INFO. <br /> + EH 13-24(REV.10/831 <br /> EN 1426 + <br />