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1 <br /> APPLICATION,FOR PERMIT <br /> f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> I Telephone (209) 466-6781 <br /> PERMIT EXPIRES 11-YEAR FROM DATE ISSUED <br /> (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, j <br /> Job Address �� L L El �'dC-s J City A2 4i1Lot Size PM <br /> j Owner's Name `r � — CA_ <br /> Address L-4.4e L'�'�'+C -` <br /> 1 <br /> _ Phone,0221^ 1-04 <br /> ContractorCt°.�A Address/ !)- <br /> License Na - Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 9d <br /> r. 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 j <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing J <br /> I7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type af,Casing Specifications i <br /> F] Public Ci Other C1 Delta Depth of Grout Seal T �J <br /> ype of Grout \Ji I Irrigation ­Approx. Depth I I Eastern Surface Seal Installed by _ <br /> Repair Work Done L Type of Pump H.P.L_ State Work [Sone .� <br /> Well Destruction ❑ Well Diameter* Sealing Material (top 50') _P,/.l cit.,_ .e{,r f �.yt,���a �w f <br /> Depth 4 <br />. P Filter Motorial (Below 50') � C <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION i I DESTRUC ON I I (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 <br /> Character of soil to a depth of 3 feet: 1 Water fable depth <br /> SEPTIC TANK C1Type/Mfg j Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Metkod of Disposal <br /> Distance to nearest: Well Foundation Property L(nd� <br /> LEACHING LINE ❑ Nor.& Length-pf lines. _ T.otal length/size <br /> FILTER BEDS <br /> ❑ Distance to nearest: Well Foundation Property Line <br /> �. <br /> SEEPAGE PITS [ I Depth.. Size .'. <br /> Number <br /> SUMPS ❑ Distance to nearest: WellFoundation Property Line <br /> DISPOSAL PONDS El <br /> hereby certify that I have prepared this application and that the work will be done in-accordanpe with San Joaquin county ordinances, state laws <br /> rules and regulations of the San Joaquin Local Health District. , and i <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." Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of thevw&k for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call f PTII required inspections. Complete drawing on r verse side. 1 <br /> Signed X •' Title: p„ ry:L,L <br /> ""� _� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date <br /> Area <br /> Pit or Grout Inspection by Date -Final inspection by a� <br /> Additional Comments: <br /> ❑ Stk 456-6781 ❑ Lodi 369-36211 ❑ 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 /> INFOFEE AMOUNT DUE AMOUNT REMITTED <br /> CASH RECEIVED By DATE PERMIT'NO. <br /> +.EH 13-24(REV.1 i H sl3..] �� '7(o3. <br /> EH la-2e /O <br />