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+ APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON ON 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. 18&2 for welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address City Phi ' Lot Size PM <br /> Owner's Name c\ {`r- 4e_• Address "21141 L- 1 +W J ! - Phone7,—q— <br /> t Address Contractor 30/03 1 Phone727' ` <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTH2 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> ry <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L�t� <br /> ❑ Industrial ,Open Bottom ❑ Manteca Dia. of Well Excavation, Dia. of Well Casing / <br /> ❑ Domestic/Private ID Gravel Pack El Tracy Type of Casing Specifications <br /> ('] Public Q Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> Irrigation ?--Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P.' State Work Done I <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> i <br /> TYPE OF SEPTIC RK: NEW INSTALLATION I 1 REPAIRIA ITION I I DESTRUCTION I lNo septic system permitted if p blic sewer is <br /> available within 200 feet.) <br /> Installation will serve: si ce_ Commercial_-_-_ Other ` <br /> Number of living units- Number of bedrooms <br /> Character of soil a depth o 3 feet: Water table dept <br /> SEPTIC TAN ❑ Typ Mfg Cap ity No. Compa nts <br /> PKG. T TMENT PLT. ❑ Method Disposal <br /> Distance nearest: Well Foundation Property ' e r' <br /> ZLEACHING LINE ❑ No. & gth lines tal le h/size I <br /> FILTER BED ❑ ance to near t: Well Foundation Property Line x <br /> SEEPAGE PITS i I Depth Size _ Nuri <br /> SUMPS ❑ Distance to nearest: Well Founda Property Line <br /> DISPOSAL PONDS ❑ <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 /> fulas and regulations of the San Joaquin Local Health Di"strict. <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 of 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 compansa <br /> tion laws of California." �""r <br /> The applicant c t r ail uired inspections. Complete drawing on reverse <br /> Signed X Title: Date: <br /> sid <br /> . > .-E A <br /> � k <br /> ���c:S <br /> FO TM ENT USE ONLY <br /> Application Accepted by no Date1-2� 1 Area <br /> Pit or Grout Inspection by Date Final Inspection by <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 9, St 95701 <br /> csk <br /> 1 <br /> FEE <br /> INFO OUNT DUE AMOUNT REMITTED SASH K 40 RECEIVE BY DATE PERMIT'NO. <br /> r <br /> + EH1 -241REV.1/951 w.s 1 ^��-Q! �� A• <br /> EH 14-28 I -`�I {J <br />