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i� <br /> 1 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT' <br /> r v it l 1601 E:•HAZEL i ON�AVE., STOCKTON, CA <br /> Telephone 609) 466-6781r7+-r 4 4��8 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AUG� <br /> I� (Complete in Triplicate) <br /> ENVIR4MENTA��I: H((��EFF,4LTH <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wkrEf4tA A9 ibYd"' h%application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. \I� <br /> CJSl <br /> Job Address PA�� Cit Size PM <br /> � � - __ ! <br /> Owner's.Narile c4 Address _ _ Phone <br /> Contractor ddress �� Qx j ��- =-t(cense No. , _..Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ }SYSTEM REPAIR ❑ OTHER 0 { <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE k <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 /> M Public ❑ Other n Delta Depth-of Grout Seal Type of Grout _ <br /> I I Irrigation / "Approx. Depth I 1 E stern }Surf meal Installed by <br /> Repair Work Done 14 Type of Pump + H.P. __ i State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Mhte al (top 501 <br /> Depth Filler Mate al(Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION l I (No septic system permitted if public sewer is <br /> a available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Others' <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 /> PKC:TREATMENT PLT. ❑ I, F Method of Disposal <br /> Distance to nearest: Well i Foundation Property Line <br /> LEACHING LINE ❑ No, & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth SizeNumber <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line ' <br /> DISPOSAL PONDS ❑ u <br /> I hereby certify that 1 ed this application and that the work will be done in accordance with San Joaquin county ordinari`oesp state laws, and <br /> rules and mgula ' s af-the-San oaquin-L'ocaLHealth-District. n. i <br /> Home owner licensed agent's ignature certifies the ollowing: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ an rson in such ma 'a <br /> as to b ome.s lec-to-workman's compensation laws of California." Contractor's hiring or suis-contracting signature <br /> certifies a following:l'I c5wy'hat* t r anc of t14tk fvrovflTBT[fits it-is issued, I shall employ persons subject to workman's compensa- <br /> tion to of Californi <br /> I,. i "' i Aa <br /> i <br /> The a plicant must 1 all re u- ins. Com ete drawing on r rs i 1 <br /> Signed — Title Date: <br /> F I DEPA MENT USE ONLY <br /> Application Accepted by Date Area <br /> 6 <br /> Pit or Grout Inspection by Date Final Inspection by Datet=�–� <br /> E t <br /> Additional Comments: �I 1 <br /> ❑ Stk 466-6781 ❑ Lodi Il.369-3621 ❑ Manteca 823-7104, ❑ Tracy .835-6385 <br /> Applicant- Return all copies to:'Environmental Health Permit/Services 11601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE- PERMIT'NO. <br /> ♦.EH13.24(REV.t i k sl <br /> EH 14-26 <br /> 'i i <br />