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9 Y <br /> APPLICATION EOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> y� 1601 E. HAZE T ON AVE., STOCKTON, CA ' <br /> Telephone (209) 466-6781 N 9VJ <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) I <br /> Application is heieby made to the San Joaquin Local Health District for a peimit 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. 1962 for welUpump and the Rules and Regulatiobs of the San Joaquin <br /> Local Health District. <br /> Job Address 8601 AN +b•axit�9 u <br /> rt11 <br /> City Lot Size PM <br /> Owner's Name Address �_yr � <br /> Phone 264"""19 <br /> Contractor Address = I License Na.yll 1313 Phone 4725 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ { <br /> PUMP INSTALLATION 41 SYSTEM REPAIR 0 ' '.OTHFR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LiNE t t <br /> FOUNDATION AGRICULTURE WILL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 0 Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> 'It) Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'I Public C1 Other fi Delta Depth of Grout Seal Type of Grout* v <br /> _ <br /> f I Irrigation n1- -Approx. Depth i I Easiern Sutfacd Seul lnstalled b .. <br /> Repair Work Done U Type of Pump ., H.P. w State Work Dbhe; . ' <br /> Welt Destruction ❑ Well Diameter Sealing Material {top 50') <br /> Depth Filler Material (Below 501 i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I i D(STRUCTION I I (No septic system permittisewe,, <br /> available within 200 feet.l <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 /> PKG, TREATMENT PLT, ❑ Method of DisposalDistance I-ohearest: Well FoundationProperty Line <br /> LEACHING LINE U No. 9 Length of lines Total length/si2dj <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size _ hlumbor <br /> SUMPS UI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that i havd 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 DRtrict. <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 issudd, 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 /> The applicant mus�llr required inspections. Complete drawing on reverse side. <br /> Signed X <br /> Si ► C +' `t <br /> g Titlo: Date: 1'�+k <br /> F, DEPARTMENT USE ONLY <br /> Application Accepted.by w <br /> Date <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection b <br /> Dat <br /> Additional Comments: <br /> (A Stk 466-6781 O Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return alt capias to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, SM., CA 95201 <br /> FEE AMOUNT DOE AMOUNT REMITTEDCK INFO yy�� GASH RECEIVED SY DATE PEMIT'N10J). <br /> EH r3L24tHEV.iin5i F +:I� �V � r�.� � �` 4C <br /> EH 11.28 E � <br /> /( I <br />