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'APPL.ICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT { <br /> 1601 E. HAZELTON AVE., STOCKTON, CA f� <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) 4 <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 /> a <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, cc <br /> Job Address <br /> c1f1 n� � City L i�� Lot Size •�, G G � PM <br /> psb C/}n1Aef V g� � r <br /> Owner's Name 1°�� bg-OdL,i16 � �d L Address -6u" °�3d�, Phone J <br /> II <br /> Contractor's Name[ !w7is 'L' rn 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 <br /> ❑ Industrial ❑ Open Bottom 1:1Manteca Dia. of Well Excavation�`i Dia. of Well Casing <br /> Type of Casing #0 VC- Specifications <br /> Domestic/Private *Gravel Pack ❑ Tracy <br /> ❑ Other El Delta <br /> Type of Grout <br /> 13 Public <br /> � r <br /> Delta Depth of Grout Seal �- <br /> ElIrrigation 14A_L�Approx. Depth ❑ Eastern Surface Seal Installed by <br /> 012, a �L Gr <br /> Repair Work Done ❑ Type of Pump �� H.P. 3 State Work Done <br /> IZd J <br /> � <br /> Well Destruction ❑ Well Diameter .r Sealing Material (top 50'! ty r <br /> Depth ®r Filler Material (Below 50') <br /> OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ available systemhin rmiitted if public sewer is <br /> Installation wl Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of sail to a depth of 3 fee . <br /> SEPTIC TANK ❑ Type/Mfg <br /> Capacity No. Compartments <br /> • Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to of <br /> Well ndation Property Line (n <br /> LEACHING LINE ❑ No. & Length of lines ength/size} <br /> FILTER BED ElDistance to nearest: Well Foundation Pro ine <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: 11' Foundation Property tine <br /> We <br /> DISPOSAL PONDS ❑ <br /> 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 /> ifies the following: <br /> nature cert "I certify thatJn the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's sig <br /> employ any person in such manner n to become subject to workman's compensation laws of California." Contractors' 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 parsons subject t Y workman's compensa <br /> tion laws of California." "' <br /> t <br /> The applicant must call r all wired inspections. Complete drawing on reverse side. <br /> i Date:. <br /> ,. Title: _..��� .� <br /> Signed v - F <br /> OR DEPARTME USE ONLY <br /> Date <br /> Application Accepted by <br /> l Date Final Inspection by r�Date <br /> P' or Grou spection by <br /> s <br /> Additional Comments: <br /> ❑ Stk 466 6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385M, f <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> J <br /> FEE CK RECEIVED BY �DATE PERNIiT'.;NO.,. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> + EH 13-24(REV.101931 Q S <br /> EH 1428 I <br />