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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' 1601 E. HAZELTON AVE.; STOCKTON, CA b Z <br /> Telephdi i J209�*466-6781 L <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l <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 i <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address ity �� -- Lot Size PM <br /> Wear 4 <br /> Owner's Name �15haess one <br /> Contractor V%A- Address -n x 11 SLicense No. !z��3 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 FLD. PROP. LINE <br /> i b 4 I±O ND�ATION AGRICULTURE WELL OTHER WELL PITS/SUMPS.-— JI <br /> INTENDED USE -��YPE O'F WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS --t <br /> at <br /> 0�Industrial ❑ Open Bottom ❑ Manteca y�Dia. of Welk Excavation Dia. of Well Casing <br /> Ls•Domastic/Private 1-1Gravel Pack L1Tracy Type of Casing Specifications <br /> ❑ Public L1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth.� 171 Eastern Surface. eal Installed by <br /> Repair Work Done El Type of Pump ��- HP. ",1 i t.f�i� - State Work Done <br /> Well Destruction ElWell Diameter Sealing 1Nlat6rW Itap 50'1 0 <br /> Depth Filler Material IBelow 50') -0 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is O <br /> available within 200 feet.► r <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms i r .J <br /> Character of soil to a depth of 3 feet: Water table depth (� <br /> SEPTIC TANK ❑ Type/Mfg capacity—..-No. Compartments <br /> PKG. TREATMENT PLT. ❑ t Method of Disposal <br /> Distance to nearest: Well Foundation t - i'�..Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total'lengtn/'size <br /> FILTER BED ❑ Distance to nearest: Well 1 Foundation Property Line <br /> l SEEPAGE PITS ❑ Depth Size i Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> t DISPOSAL PONDS ❑ <br /> I hereby certif have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and ulations o e San Joaquin Local Health District! � k <br /> Hama n8r-oriice�sed`a ent''s signature certifies the'followinb:-'I-certifythat-in-the performance-of for-which'this-p'ormit Wissued,I-shall'not <br /> amp y�any person in su h manner as become su e t to workman'ss.,ompensation laws�df California.,,' <br /> Contractor s hiring or sub-contracting signature <br /> .a ce ifie�S the;f44110WIPg: c "fy that in a or nc of the Worlt for which]thistipermleis issued,I'shAl employ persons subject to workman's compensa <br /> ti n'laws of California.' ' <br /> i e applicant must f all re uire cti n ample ers , .3 f71 <br /> Signe V Title: Data: }�+ ��• <br /> FOR DEPARTMENT USE ONLY C� <br /> Application Accepted by `" DateeS '. <br /> Pit or Grout Inspection by Date Final Inspection by �^" DIt� <br /> Additional Comments. f <br /> ElStk 466-6781 ❑ Lodi 369-3621 EJManteca 823-7104 1-1Tracy 835-6385 (0 Z r0 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952,. <br /> C7a. C'? <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE T'NO-0 +eE <br /> C!3 <br /> r + EH EV.t/e5> INFO g <br /> EH 1426 <br />