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v1 4,1-,t3 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466 6781 <br /> PERMIT EXPIRES 1 YEAR FROM:DATE ISSUED JO 2 <br /> (Complete in Triplicate) ry f AL HEALTH <br /> �1Vti RtZ E., <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described ETF s�aplpl'k*ion is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Ragulations of the San Joaquin <br /> Local Health District. <br /> ri !! <br /> Job Address ~' City Lot Size PM <br /> Owner's Name /` -� Address 7/ 641 Phone <br /> Contractor O� -Address T A License No/60 Phone /44_W' <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 PITSISUMPS p, <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS }J <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing d <br /> tk Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation #--- pproxrOapth-­[D-Eastern — -- Sur;aca-Seal lnstalked by V� + <br /> Repair Work Done Type of Pump -(.(��" H.P. 1 State Work Done f <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION'S REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> -Installation will serve: ResidenceCommercial_ Other <br /> i '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 Disposal <br />' Distance to nearest- Well 'f Foundation Property Line <br /> LEACHING LINE �❑ No. & Length of lines Total length/size <br /> FILTER BED p'.-Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth T - Size Number <br /> i SUMPS ❑ Distance to 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, and <br /> rules and regulations of the San Joaquin Local Health District. <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 issued, I shall not <br /> employ any person in such mariner 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 must call for all requ' d inspections Complete drawing on reverse side. - <br /> Signed <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> „ <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 /> IFEE <br /> NFO AMOUNT DUE UNT REMITTED CASH RECEIVED BY DATE PERMIT''NO. <br /> + EH 13-24 1REV.1/B 5) <br /> EH 14-28 <br /> r <br />