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' t APPLICATION FOR PERMIT <br /> SAN JOAQUIN-LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , <br /> i <br /> *" (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.;.r <br /> Job Address ity, [: 641P� Size PM <br /> Owner's Name ddress rj7VAF Phone <br /> Contractor Address R�C License No.�Y_J Phone -IC+ <br /> TYPE OF WELL/.PUMP:----.NEW WELL .D WELL REPLACEMENT El�--DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _.r f- - DISPOSAL FLO. 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 /> n <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy .^�`,Type,,of Casing Specifications <br /> © Public ❑ Other ❑ Delta ` 'Depth of Grout Seal Type of Grout <br /> El Irrigation --Approx. Depth JEl Eastern Ni.Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter + _ Sealing Material atop 501 <br /> Depth 4-17 Filler Materia14-661 w 50') <br /> TYPE OF'SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION- DESTRUCTION ❑ lNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence JCommercial-_ .Other`- t 1 <br /> Numbertof living units:_/_ Number of edrooms`-D 1 <br /> Character of soil to a depth of 3 feet� Water table depth <br /> SEPTIC TANK( ❑ Type/Mfg r"'"'te -- Capacity No. Compartments <br /> PKG. TREATMENT PLT. LJ r ; z Method ofbisposal <br /> Distance to nearest: Well Foundation Property Line '. <br /> LEACHING LINE No. & Length of lines Total length/size r ' <br /> .r - <br /> FILTER BED ❑ Distance to nearest: WeII"'"�` iFoundation_..0 Property Line 10 ' <br /> SEEPAGE PITS �epth f Size__ - 1 Number <br /> SUMPS ❑��'Dist8n0e to neares **,'We'll e'll. r Foundation I 'Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done ir1 a cordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin'1Local Health District. <br /> +a Home owneror licensed agent's signature'certifies the following;"II 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 compe'nsatior`la 9' 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 Js issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applic at call for all_ quire spec" s. Complete drawing on.r,verse-side. ' _.�,,,,,,,,, <br /> Signed q� <br /> Title: � ^�--f Date: 1 <br /> l . <br /> FORyDEPAFiTMENT USE ONLY <br /> Application Accepted by _Dateol <br /> r Area <br /> Pit or Grout Inspection by Date + Final Inspection by pate <br /> • - i <br /> Additional Comments: <br /> D Stk 466-6781 'Lodi 369-3621 D Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE t <br /> i <br /> INFO EH 14-20 ///AMM�IO�UNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. <br /> If, <br /> + EH 13-24{REV. /a51 //f <br />