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d <br /> Way <br /> S ' <br /> Y 9 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL, HEALTH DISTRICT /d, <br /> 1601 E. HAZELTON AVE, STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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. Thls application is <br /> made in compliance with San Joaquin Co Ordinance No.549 for sewage or No. 1862 for well/ and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address C <br /> ze PM <br /> Owner's Name rest-.i4'- e � /� 7 <br /> dress Phone "" rG. <br /> L/ i <br /> Contractor's Name �' cense No. � � 7 1 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> TM <br /> -DISTANCE TO NEAREST: SEPTIC-TANK r- SEWER LINES--.DISPOSAL FLD. PROP..LINE_ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS � 4 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS d <br /> ❑ Industrial <br /> [TO 11 Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing r� 1 <br /> ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing <br /> Specifications � <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal <br /> C1 Irrigation _A Type of Grout <br /> pprox. Depth stern S� ace Seal Installed by ., d <br /> Repair Work Done Type of Pump H,P <br /> State Work Done (' <br /> Well Destruction El Well Diameter Sealing Material [top 50'1 ! f� <br /> Depth Filler Material (Below 50') ? ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is yl <br /> ' <br /> Installation will serve: Residence_ Commercial available within 200 feet.) <br /> _ Other "i <br /> Number of living units: Number of bedrooms t <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. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line f <br /> LEACHING LINE [I No. & Length of lines <br /> Total length/size +r <br /> FILTER BED ❑ Distance to nearest: Well Foundation ,r l <br /> Property Line <br /> SEEPAGE PITS ❑ Depth Size <br /> Number <br /> —SUMPS--- A*_•- ' <br /> t <br /> SUMPS'".x"'Ae `�-` ---,L]---,L] Tbistance to nearest:^ Well '-- Foundation"�:�� <br /> `�"' �property Line � � "`'""'�""P'� --�'+�^^rk�° � <br /> DISPOSAL PONDS ❑ f / .L l <br /> I hereby certify that I have prepared this application and that the work wil! be done in accordance%igh)SBn Joaquin county ordinances, state laws, and �r <br /> rules and r ao the San Joaquin Local Health District. _. . <br /> emnle an er or license agent's signature certifies the followyl <br /> ing: "I certify that in the performance of the work for which-this•permit-is'issued, Ishall not <br /> P Y Parson in su h manner as to become subject t rkman's compensation laws of California."Contractor's-hiring or sub-contracting signature <br /> oe ies the followin I3 g g <br /> g:'' certify thatJn,the pe or nce t work for which this permit is issued,I shall employ persons sub e <br /> —i–ti o laws'of Ca' ni s j-ct.td wUrkman's compensa- <br /> 7 applicant m call for ail! requi d ' T plate drawing on rEverse side. <br /> Signe rte' Title: 2- <br /> Date <br /> { <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by _ <br /> 12 3 ._� <br /> Date � Area <br /> Pit or Grout Inspection by DateFinal Inspection by Date 1-7 <br /> 6J 0 q <br /> Additional Comments: <br /> ❑ Stk 466-6781 -.. ❑ Lodi 369-3621 ❑ Manteca 82:3-7104 ❑ Tracy 835-83851- <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 " <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED BYDATE PERMIT'NO. <br /> I <br /> + EH 13-24 aREV.10!$31 <br /> EH 1428 � /'3 <br />