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i <br /> ' APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON 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.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations f he San Joaquin <br /> Local Health District. !O_'UGl� <br /> Q City of Size_�� PM p� <br /> Job Address • 165E-4 y <br /> j W rfh _ Phone y <br /> k Owner's Name r s Address � ` —s c�e��1 b <br /> Contractor <br /> Add ess E c�1v License No.�crs>s --Phone_ (� <br /> TYPE OF WELL/PUMP: NEW WELL.( WELL REPLACEMENT F1 DESTRUCTION 0 <br /> PUMP INSTALLATION 11SYSTEM REPAIR 71OTHER X tA0NyV' P WeL`PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL Pl7SISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4 <br /> iis Dia. of Well Casing <br /> El industrial ❑ Open Bottom 17 Manteca Dia. of Well Excavation . Specifications <br /> ❑ Domestic/Private [Gravel Pack ❑ Tracy Type of Casing <br /> Type of Gi Uln <br /> l i-i Public Rf ❑ Other ❑ Delta Depth of Grout Seal <br /> 1 1 Irrigation )(V �Approx. Depth l 1 Eastern Surface Sea! Installed by G <br /> F Repair Work Done ❑ Type of Pump H.P, State Work Done <br /> p Well Destruction ❑ Well Diameter '`� r! Sealing Material (top 501 20h C - LSE <br /> Depth Mb&I 9AN 0 -_ <br /> Filler Material (Below 50'1 ��—&.� _4 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION l l DESTRUCTION l I (NoSepttic systhin m feet.)mited if public sewer is <br /> available r <br /> ` Installation will serve:' Residence— Commercial_ Other <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 /> ' PKG. TREATMENT PLT. ❑ Method of Disposal <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 /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS Ll 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 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 /> r - <br /> I The applicanic— <br /> t call for all re uire spections. Complete drawing on reverse side. <br /> Signed X Title: �F�f �r�f S� Date: <br /> In'C r FOR DEPARTMENT USE ONLY " <br /> Application Accepted by Date AM Area <br /> Date3 /by y <br /> Pit or Grout Inspection by Dat — Final Inspection by <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 9520] <br /> e FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE WPERMIT'NO. <br /> INFb <br /> er <br /> + EH 13-24(REV.5/x 51 L <br /> EH 14-26 <br />