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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 /> hit (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. !�I� <br /> Job Address / � ��' / �A/ t _ Cit Lot Lot Size PM <br /> r qp <br /> Owner's Name R IGle'Le l G V IV1 Address Phone <br /> �/� -2, / <br /> Contractor�_N �"�J4Y� 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 FLU. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I MINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> i © Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Public T 71 Other ( ] Delta Depth of Grout Seal Type of Grout <br /> t I Irrigation I-Approx. Depth I 1 Eastern Surface Seal Installed by. <br /> Repair Work Done ❑ Type of Pump H,P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing,Material (top 501 <br /> 'Depth Filleaterral'LBelnw 50'i v <br /> f <br /> ­TY-P.fi--01`-SERTIG WORK:--NEW-INSTALL-ATJON-.I,I-.�REPAl11/.AOf34TIDN-I-I—DEST�FtUC-TION^�INo-sep[ic•-system-pertnitded-i(-public-sewer is <br /> 1 II available within 200 feet.) <br /> ; Installation will serve: Residence_ Commercial_I Other <br /> 1, J'Number of living units: Nuintter of bedrooms <br /> Character of soil to a depth Ilk 3'felt: Water table depth <br /> SEPTIC TANK '- 1�'_Type/Mfg 1'1: Capacity - No. Compartments <br /> i. <br /> PKG. TREATMENT PLT. ❑ �� Method of Disposal_ 1 <br /> Distance to nearest: Well Foundation Property Line ` �I <br /> ' LEACHING LINE ❑ -No. & Length of lines Total length/size <br /> FILTER BED ❑ IDistance to nearest: Well Foundation Property Line {I, <br /> SEEPAGE PITS l I Depfh ! Size F j Number <br /> SUMPS Ll Distance to nearest: Well =-� Foundation Property Line <br /> p Y <br /> DISPOSAL PONDS ❑ �I! <br /> hereby certify that I have preioared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and illi <br /> rules and regulations of the San Joaquin Local Health District. 6 { <br /> Home owner or licensed agentis signature certifies the following; "I certify that in the performance of the work for which this permit is issued, I shall not R <br /> employ any person in such manner as to become subject to workman's compensation iawS of California." Contractor's hiring or sub-contracting signature <br /> r 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- r <br /> lion laws of California." i e <br /> The applicant must call for all II quirodirifpee ins. Complete drawing on reverse side. <br /> 5, Signed X � ��, .>C,. -"�,,,�. .�—Title: .: __ Date: l <br /> "DEPARTMENT USE ONLY .J <br /> pplication Accepted by IAS Data r F Area d <br /> }it or Grout Inspection by I Date Final Inspection by e` ���f Date + <br /> Additional Comments: I' '^° <br /> 0 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 /> IFEENFO AMOUNT DUE AMOUNT'REMIT-rEd K RECEIVED BY DATE PERMIT NO. <br /> .. r -.-.. <br /> INFO <br /> + EH 13-21(REV.t i n 51 ✓ ���� / /� <br /> EH 14-M - f� <br />