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! p <br /> E APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCALWEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' <br /> (Complete in Triplicate) a <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 N 549 fo sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local-Health District. � v/701 - <br /> c1 1 <br /> l � i <br /> Job Address t u BOO � <br /> , , 0 ��G City d t Lot Size P <br /> SCM <br /> Owner's Name Address 'L 4 Lo' `�` V C e <br /> —_..� Phone <br /> Contractor Address ell, (cense IV ,2,��Phone <br /> I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 ❑ <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 Q <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of�Casing Specifications G <br /> r <br /> O Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> P . yP <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> II Repair Work Done ❑ Type of Pump H.P. I State Work Done <br /> Well Destruction Well Diameter Sealing Material /top 50'1 <br /> Depth .f Filler Material (Below 501 _ <br /> TYPE OF SEPTI ORK: NEW INSTALLATION ElREPAIR/ADDITION,❑ DESTRUCTION {No septic system permitted if public sewer is <br /> ; ! <br /> � -/& i, available within 200 feet.) t <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living'units:.. Number of bedrooms a <br /> i= <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 /> ii <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 /> t SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Weil Foundation Property Line <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 /> 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 st call f a equired ins ns. Complete drawing on reverse side. <br /> Sighed Title: Date: I! 4 5� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 0 Area 11 <br /> Pit or Grout Inspection by Date -i` Final Inspection by Date <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 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CC--A RECEIVED BYT . <br /> DATE. PERMIT"NO. <br /> + EH 13-24{REV.1/a 51 O I 1 <br /> EH 14-26 <br />