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APPLICATION FOR PERMIT f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT PAN'eir <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA Ptcal� ® <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED P(SANjO QU�V f993 <br /> (Complete in Triplicate? _ �NVIRON�MENFALTH SE y <br /> t ftcation is <br /> Application is hereby made_to the San Joaquin Local Health District for a pe imit to construct and/or install the work hereiKtle ftBPPmade in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulatio �tj�loaquin i <br /> Local Health District. ` - i, 6 l <br /> fit * <br /> d �. City Lot Size .4 ` PM <br /> Job Address /�r� ,q <br /> p ! �il Phone 3,67 -f7J O I <br /> Owner's Name ,c �' - '``� Address -7 <br /> Phone`G <br /> Contractor s 2License No. <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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> f irrigation �pprox. Dep h EJ Eastern Surface SAM Installed by r <br /> t Repair Work Done Type of Pump H.P. State Work bone <br /> E } <br />� ; Sealing Destruction ❑ Well Diameter 9 Material (top 50') <br /> Depth Filler Materiel (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [1 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> 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: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> I PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation . Property Line <br /> LEACHING LINE L1No. & Length of lines Total lengthlsize <br /> s <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> I <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS 1-1Distanceto 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;an <br /> rules and regulations of the San Joaquin Local Health District. <br /> following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the follow <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 /> The applicant st all for all requ' d inspections. Complete drawing on reverse side. &a�X <br /> r �� <br /> Signed Title: -e4.� ate' <br /> FOR DEPARTMENT USE ONLY l f <br /> k Application Accepted by � J�L/ � "' — Date Area'-.1— <br /> rea` <br /> fate <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additionai Comments: <br /> ❑ Stk 4664781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> t <br /> INFO WCA RECEIVED FlY DATE <br /> FEE AMOUNT DUE AMOUNT REMITTED S f PERMIT'NO. <br /> I + EH 13-24{REV.I/a s) <br /> EH 1426 l/ <br />