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w <br /> t APPLICATION FOR PERMIT <br /> ` SAN JOAaUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE.,.;STOCKTON, CA <br /> 'Telephone (209) 466.6781 <br /> PERMIT EXPIRES 1 YEAR.-FROM DATE ISSUED <br /> (COf1'll}lete 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 compliance with San Joaquin County Ordinance,No.549 for <br /> Local Health District: sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Job Address Ca� i7 E_Y } Ot iijQ t.�` t. .0 . ? . <br /> - City Lot Size <br /> Owner's Name" - ~, .. ...,. v a PM <br /> Address <br /> / Phone F <br /> Contractor LfteDr)�,Ot­ f = — <br /> Address �� ✓- G1G I f"[Y�,c 2� �.� �7 _ <br /> TYPE OF WELL/PUMP: " <br /> NEW WELL � � WELL REPLACEMENT [I License No. Phone O <br /> DESTRUCTION ❑ V) <br /> PUMP INSTALLATIO � 4� SYSTEM REPAIR ❑ ' <br /> DISTANCE TO NEAREST: � OTHI�R El <br /> SEPTIC TANK � SEWER'LINES DISPOSAL FL0. PROP. LINE 1—(/ �- <br /> FOUNDATION AGRICULTURE WELL, <br /> OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL_., PROBLEM AREA CONSTRUCTION SPECIFICATI <br /> ❑ Industrial ❑ Open Bottom Manteca `� <br /> Dia. of Well Excavatio Dia. of Well Casing <br /> Domestic/Private _ �f Gravel Pack- Tracy T 1 <br /> ❑ Public e � <br /> Type of Casing Specifications <br /> fi 1 - ? ❑ Othe"r ❑ Delta <br /> Depth of Grout Seal Type of Grout <br /> `❑ irrigation �,l�_�Approx. Depth ❑ Eastern <br />'1 Repair Work Done"'�❑ Type of Pump Surface Seat Installed by o _ . <br /> H.P. State Wprk Done <br /> . Well Destruction ❑ Well Diameter <br /> Sealing Material (top 50,) <br /> / Depth. Filler Material (Below 50') �* <br /> .�' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/AuuI1ION ❑ ' DESTRUCTION ❑¢(No l^septic system permitted if public sewer is <br /> Installation will serve: Residence_ Commercial_ Other available within 200 feet.) t <br /> 1 <br /> Number of living units: Number of bedrooms ' <br /> .Character of soil to a depth of 3 feet: y <br /> SEPTIC TANK ❑ Type/Mfg CapaciWater table depth ` <br /> ty <br /> PKG. TREATMENT PLT. ❑ No:Compartments <br /> Distance to nearest: _ Well. Method of Disposal <br /> Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines—* <br /> Total length/size- <br /> FiLTER.BED ❑ "Distance to nearest: -_-Well <br /> Foundation Property Line <br /> SEEPAGE PITS ❑ Depth -"' " <br /> 4 Size Number i <br /> SUMPS ❑ Distance to nearest: Well <br /> DISPOSAL PONDS El Foundation Property Line <br /> I herebycertify Y <br /> fy 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. I <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this <br /> permit is issued,employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring osub-contracting l signature <br /> tion certifies the following: "I certify that in the performance of the work for which this on la is issued, I shall C to <br /> tion laws of California." p employ persons subject to workman's compensa- <br /> The applicantm call r all quired s coons. Complete drawing o�re,, side. <br /> Signed X <br /> Title: Date: - %^ % <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Area !� <br /> Pit or ro Inspection b Date �� ~ <br /> Final Inspection by Date <br /> Additional Comments; - # <br /> ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 9 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> e <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE <br /> /f PERMi"NOj. <br /> ♦ EH 13-24{REV.lits sl <br /> EH 14-28 C ... V P� � �75,SNl _. <br /> l.fI � � j <br />