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! APPLICATION FOR PERMIT <br /> fr. b SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 4 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) <br /> f 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. L <br /> Job Address 1 0 q :7 f p� J X City Ej44 /QMLot Size 26- PM <br /> t Owner's Name II -e-+e r ma v- n I //�� <br /> Address Z- 2 E_ tOn e tJ 4 � Phone <br /> Contractor F PIMP Address S ee Roldr1 ! <br /> Q .License fQa. .7 0' 7 Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION I%l SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE LID) <br /> Q! <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEGIFICATIONS $. <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia:of Well Excavation,- Dia. of Well Casing <br /> ❑ Domestic!Private �1 Gravel Pack ❑ Tracy Type_of_Casing - ---� _ specifications _ <br /> s ❑ O er t ❑ Delta Depth of Grout Seal T {r ype of Grout�9.r <br /> tion �4'�pprox. Depth I } Eastern Surface Seal Installed by <br /> Work Done L7 Type of Pump sub ._, H.P. _ � _ State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 _ <br /> t TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (NO septic system permitted if public sewer is <br /> available within 200 feet.► <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms r ^ 1 <br /> Character of soil to a depth of 3 feet: IWater table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> 1] <br /> l Distance to nearest: Well Foundation Property Line ' <br /> LEACHING LINE ❑ No. & Length of lines`" Total length/size <br /> FILTER BED ❑ Distance tc nearest: Well Foundation Property Line r <br /> IN <br /> SEEPAGE PITS t I I. Depth Size <br /> - Number <br /> SUMPS �. ❑ Distance to nearest: Well 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 DiMrict. <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 pe- <br /> ' <br /> tion laws of California." sans subject to workman's compensa- <br /> The applicant u t calf for all required inspecti'ns. Comple;;�rwingon reverse side.Signed X itle: Date: <br /> {� `�;, FO DEPARTMENT USE ONLY l <br /> Application Accepted by n� \1G Date X0V' L tea <br /> Pit or Grout Inspection b. Dat�/� Final Inspection b Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 1369-3621" Cr Men ca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return afi"copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> FEF AMOUNT DUE AMOUNT REMITTED <br /> INFO K FIE EIUED BY DYE I7' <br /> + EH13-24 IREV.I/H 5f w 2 <br /> EH 14-26 �] �C?O + ' <br />