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4 <br /> S- } <br /> APPLICATION FOR PERMIT7 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT _77-79? <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES TYEAR 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. /qj)x l-1 V <br /> t1f >!'ct� c ity as J mac-?V Lot Size PM <br /> Jab Address I ` l � ,{�n <br /> WN <br /> Address 1�(9 L1 Lj �C}c� ,iK � Phone <br /> Owner's Name k <br /> Address ~ - License No - - -Phone <br /> ...: �. <br /> Cpnfractor - "" � "` - - <br /> TYPE OF WELLlPUMf?:-_„•, _- NEW WELL ❑ WELL-REPLACEMENT El DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑.'y'; OTHER ❑ <br /> DISTANGE TO .:.SEP_T,IC TANK., SEWER LINES <br /> NEARESTDISPOSAL FLD. PROP. LINE <br /> x <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> FOUNDA�I6N�`-"` _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 13Industrial N Open Bottom ❑ Manteca Dia. of.Weli Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing A--- - _ <br /> Specifications <br /> F1Public Cl Other F1Delta Depth of Grout Seale Type of Grout <br /> E I Irrigation on <br /> Approx. Depth I 1 Eastern Surface Seal Installed by <br /> `- <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done — <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION 1 1 DESTRUCTION i I (No septic system" ermit;publc <br /> M1 available within 200,feet <br /> Installation will serve: Residence�-- Commercial_"` Other <br /> Number of living-units Number of bedrooms Character of soil'to a depth of 3 feet: Water table depth' <br /> SEPTIC TANK ❑ TypelMfg Capacity + ;1No. Compartment'Method of DisposPKG. TREATMENT PLT. ❑ - Foundation Property LineDistance to nearest: WeH <br /> LEACHING LINE ❑ No. & Length of lines �1 r - TotaLlength/size <br /> =t:ze _ <br /> FILTER BED ❑ Distance to nearest: Well ,3 Foundation -- Property Line <br /> SEEPAGE PITS l I Depth s Size y- Number � �-44���� <br /> SUMPS L] Distance to nearest: Well #Foundation ` Pro ��y <br /> perty Line�t- - <br /> ' - <br /> DISPOSAL'PONDS ❑ ` <br /> I hereby certify that{ 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-rr <br /> i tion laws of California." <br /> The applicant Lfflt call for all required inspections. Complete drawing on reverse side. , <br /> Signed X <br /> Title: Date: <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by_ Date Area—4 <br /> do P <br /> Pit or Grout Inspection by Date ` "l"Finaf•fn'spection`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 /> I <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 9 RECEIVED Y DA E PERMITNO. <br /> CASH <br /> INFO , - H <br /> + EH 13-24(REV.I/H 51 �,5� CW*�Y� �/ " —331 <br /> EH 14-2e <br />