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t <br /> APPLICATION FOR PERMIT <br /> yrJ z T <br /> t SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE:TON AVE., STOCKTON, CA <br /> Tefephone (209) 466-67$1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application i:,he.aby made to the San Jcaquin 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 Vrolinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> I Local Health District <br /> R <br /> f. <br /> Job Address r <br /> City o S, PM <br /> Owner's Name G 1 � asL <br /> Address L <br /> lr Phone <br /> Contractor wU[%fitL. <br /> Address c I <br /> TYPE OF WELL/PUMP: License No. b(�.► phone <br /> NEW WELL ❑ WELL REPLAC NT DESTRUCTION ❑ ,Y <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES ., OTHER ❑ <br /> FOUNDATION { <br /> - DISPQSAL FLD. PROP, LINE <br /> AGRICULTURE WELL .. <br /> OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r' ,t <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy T Dia. of Well Casing <br /> ❑ Public Type of Casing i r <br /> ❑ Other ❑ Delta Specifications <br /> Depth of Grout Seal <br /> flrrigation' __Approx. Depth ❑ Eastern 4 Type of Grout ,# <br /> Repair Work Done ❑ Type of Pum Surface Seal Installed by n t ) <br /> j�H.P. _ t <br /> Well Destruction ❑ Well Diameter ' ,-�_ State Work Done, <br /> Sealing Material <br /> Depth Filler Material {Below 50')r fIF <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑- DESTRUCTION ❑ fNo septic system permitted if publ <br /> } sewer is ~� <br /> Installation will serve: Residence available within 200 feet.) <br /> . Commercial� Other ..� <br /> Number of living units: Number of bedrooms y <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Water table depth <br /> �� t- <br /> PKG. TREATMENT PLT. El CapacityNo. Compartments <br /> Distance to nearest: WellFoundatiMethod ofD isposal <br /> on Property Line <br /> LEACHING LINE O No. & Length of lines - <br /> FiLTER BED Total length/size <br /> ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PiTS ❑ Depth <br /> Size <br /> SUMPS LJDistance to nearest: Well Number <br /> DISPOSAL PONDS ❑ Foundation Property Line . <br /> I hereby certify that 1 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 manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature t <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- 4 <br /> tion laws of California." T' <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X <br /> Title: �� p f <br /> FOR DEPARTMENT USE ONLY n <br /> Application Accepted by } Y AAd' <br /> Date `� �"`�� Oa-�3C�1. <br /> Area <br /> Pit or Grout Inspectio by f <br /> Date Final Inspection by <br /> Additional Comments: Date <br /> ❑ Stk 466-6781 LA Lodi <br /> 3�1 ❑ Manteca 823-7104 L2 Tracy 835-6385 <br /> Applicant Return alt copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT INFO DUE EAMCE)UNTREMITTED i <br /> RECEIVED BY <br /> CASH DATE PERMIT'NO. <br /> + EH 13-24(REV.iia51 <br /> EH 14-28 ...._ 277?) Z-2-7-J7 <br />