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APPLICATION FOR PERMIT "` ,r <br /> f SAN JOAaUIN LOCAL HEALTH DISTRICT <br /> 160] E HAZEL i ON"AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 5g_ <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> "s (Complete in Triplicate) <br /> 11 <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. 1851 for well/pump and the Rules and Regulati ns of the San Joaquin <br /> Local Health District. <br /> Job Address * City ��. Lot Size PM <br /> ' � Address � l JA Phone <br /> Owners Name <br /> Contractor RMS' Address /.W 1A,�/Z-G License No. talvf4 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 FLID.-Jeov PROP. LINE aZ <br /> FOUNDATIONS- AGRICULTURE:WELL- ..OTHER WELL PITS/SUMPS <br /> w <br /> IN USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I Z- Dia. of Well Casing <br /> y9i <br /> Domestic/Private IjGravel Pack ❑ Tracy . Type of Casing Specifications ' <br /> [DPublic ll Other EI Delta fy f Depth of Grout Seal :D 7 Type of Grout 0� "f t <br /> Irrigation 15Approx. Depth ❑ Eastern + Surface Seal Installed by - f 4 <br /> Repair Work Done ❑ Type of Pump spiff HrP. State Work Done t <br /> Well,Destruction ❑ Well Diameter Sealing Material {top 501 ' !0 <br /> I Depth Fillers Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> I available within 200 feet. f <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms E <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> t PKG. TREATMENT PLT. ❑ { Method of Disposal <br /> Distance to nearest: Well Foundation Property Line ' <br /> r_LEACHING LINE ❑ No. & Length of lines Total length/size <br /> ,.FILTER BED !'*�, ���`>]�,Distance to nearest Well Foundation Property Line <br /> 4 t <br /> SEEPAGE PITS ❑—Depth# } Size Number t <br /> I SUMPS ❑ ,Distance-to.nearest., L'-`Well-��. Foundation Property Line <br />� �. . <br /> NDS- <br /> DISPOSAL PO13. - LTJ - � ..� <br /> I hereby certify that I have prelsared this'application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> e rules and regulations of the San Joaquin"Local H6alth District. <br /> Home owner or licensed agent's signature certifies`[he following:."I ce.rW that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such mariner as to E ecome 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 far which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." _..,, ... j, ,.r...�...-., ��C.: ..-�.--•-- --� — - -mow - <br /> ,iThe-applicant` II r all.re it spections. Complete drawing on reverse e. <br /> t <br /> Signed _Title: J Date: ` t <br /> �y <br /> { FQA DE RTMEIYT USE ONLY <br /> Application Accepted by Date Area <br /> or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> _ k t❑ 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 /> <, <br /> FEE +AMOUNT DUE AMOUNT,REMITTED CASH, RECEIVED BY DATE PERMIT`'NO. <br /> INFO L <br /> 163 7 <br /> a EH 13-24 tREY.1/951 /0 ,3.01D <br /> EH 14-28 <br />