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s i <br /> APPLICATION FOR PERMIT <br /> F SAN JOAO.UIN LOCAL HEALTH DISTRICT <br /> E 1601 E. HAZELTON AVE., STOCKTON, CA r <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. 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.: <br /> Job Address City '"tot Siie 7 9 X 150 PM <br /> I <br /> Owner's Name J?e9-. 'Address Phone �t <br /> s <br /> t <br /> Contractor Address License No. Phone <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 PITS/SUMPS <br /> INTENDED USE TYPE OF WELL : PROBLEM AREA CONSTRUCTION SPECIFICATIONS s <br /> "❑ Industrial " ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> eN <br /> ❑ Domestic/Private - «' ❑ Gravel Pack - ❑ Tracy -» .. +.—Type of Casing Specifications a <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump -H.P. State Work Done ry i <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 y ! <br /> Depth Filler Material (Below'50') �✓ <br /> N <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIR/ADDITION ❑ DESTRUCTION No septic system permitted if public sewer is , <br /> `.>s r11` . available within 200 feet.).___ _ice N <br /> Installation will serve: Residence_ Commercial Other <br /> 'Number of living units: Number of bedrooms r't t-k <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. ❑ ' 1 Method of Disposal 1 <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines. Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i SEEPAGE PITS ❑ Depth Size Number `S <br />' SUMPS ❑ Distance to nearest: Well F`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 manner 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 mus II for lire tions. Complete drawing on reverse <br /> side. <br /> Signed X Title: Date: V � I <br />` FOR DEPARTMENT USE ONLY <br /> ' Date ' " Area <br /> Application Accepted j <br /> Pit or Grout lnspecti Date Final Inspection by 4�r— Date <br /> os�]� '®B ✓ Ov t3\. ,F-1 k- {'Ly 6 07 <br /> Additional Comments: " <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835-6M 94; �;q <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 CCAKSH RECEIVED BY DATE PERMIT N0. <br /> INFO /A <br /> + EH 13-24(REV.1 a5) tJ V �C - <br /> EH 14-28 ••]"7 <br /> 4♦ <br />