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b 7 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />` 1601 E. HAZELTON AVE., STOCKTON, CA <br />' Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 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. <br /> Job Address L <br /> ` City Lot Size C PM <br /> Owner's Name c i Address of 9,9-- <br /> Phone O <br /> Contractor's Name h G License No. c <br /> TYPE OF WELL/PUMA: NEW WEL Phone <br /> WELL REPLACEMENT DESTRUCTION Q <br /> PUMP INSTALLATiO SYSTEM REPAIR ❑ OTHER ❑ (� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES '� XS-" `+��1 1 � <br /> DISPOSAL FLD. PROP. LINE - �r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca .Dia. of Well Excavation <br /> Dia. of Well Casing <br /> Domestic/Private Gravel Pack ❑ Tracy Type of Casin , <br /> Q Public ❑ Other Specifications o <br /> ❑ Delta Depth of Grout Seal Type f Grout <br /> ❑ Irrigation ,� Approx. Depth ❑ Eastern Sura Seal Installed bye!2'%-'r <br /> C� r,. <br /> Repair Work Done ❑" Type of Pum v G <br /> YP p � H.P. State Work Done c <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth - <br /> p Filler Material (Below 50'} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ bESTRUCTION ❑ INo septic system permitted if Pais se;7r is <br /> Installation will serve: Residence Commercial_ Other available within 200 feet.} <br /> r <br /> Number of living units: Number Of bedrooms � <br /> Character of.soil to a depth of 3 feet: <br /> SEPTIC TANKS Water table depth <br /> ❑ Type/Mfg Capacity No. Compartments <br /> PKC. TREATMENT PLT. ❑ -. <br /> Method of Disposal <br /> Distance to nearest: } Well '� Foundatibn `- ` Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS `" ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <br /> I 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'District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work The which tRis iiermit'Is issued;f 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 r <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- <br /> tion laws of California." <br /> The applic st call for all req.' ins ctioris. C plete,drawing on reverse side. <br /> .-� <br /> Signed Title: <br /> Date: <br /> C % 04�7 FOR DEPARTM T USE ONLY <br /> AppGcat_ Accepted by Date 4LArei� <br /> t �p'� <br /> Pi r Grou Inspection by — Date Final Inspection by <br /> A nal Comments: <br /> ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 ` <br /> Applicant- Return all Opi to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 l <br /> FEE AMO D E AMOUNT REMITTED CK { <br /> CASH RECEIVED 6Y DATE PERMIT"N0. <br />+ EH 13-24 IREV.10!831 <br /> EH W25 <br /> - -7 t.lf <br />