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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T 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 Or nance No.549 for <br /> Local Health District. sewage or No. 1561 for well/pump'and the Rules and Regulations of the San Joaquin <br /> qtr � T,-& <br /> Joh Address � <br /> " City /QC, Lot Size <br /> PM <br /> Owher's_Name �✓��l_ (/t t��L7_ _ Address Phone <br /> 'Contractor ra Pf� T1s <br /> i Address t License No. 67+1(125'Z Phone Z— <br />! TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ �DESTRUCTION 11PUMP'iNSTALLATION "❑ -SYSTEM REPAIR ❑ _ ' <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ <br /> SEWER"LINES '�DfSPOSAL FLDtO�� PROP. LINE <br /> T FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIS <br /> ❑ Industrial ppen Bottonl+ �p Manteca Dia. of Well Excavati Dia. of Wefl Casing NISQomestic/Private /TYPE <br /> Gravel Pack Xtacy, Type of Casing S f <br /> f ❑ Public ❑ Other r pecificatiom <br /> ❑ Delta Depth of Grout Seal T <br /> -` - o Illi ation' Type of Grout rcJ�ai�0 <br /> g i -�pp►ox. Depth M Eastern, Surface Seal installed by r1 <br /> Repair Work Done El Type of Pump H.P>" State Work Done_ ~' <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Materi I{Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0',4 DESTRUCTION ❑ (No septic system , <br /> " available within 200 feet.) if public sewer is <br /> Installation will serve: Residence_ Commercial_ "Other <br /> Number of living units: Number of bedrooms ,�� <br /> Character of soil to a depth of 3 feet: G <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg <br /> PKG. TREATMENT,PLT. ❑ <br /> Capacity !!! No.,Compartments f <br /> � t <br /> ,-- Method of Disposal <br /> Distance to nearest: Wef) Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines x 'r <br /> Total length/size <br /> FILTER BED ED Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS i ❑ Depth Size Number ^ <br /> SUMPS <br /> ❑ Distance to nearest: Well Foundation T Property Line f , <br /> DISPOSAL PONDS ❑ s <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 Sari 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- <br /> tion laws of California." { <br /> The applicant for all requir spections. Complete drawing on rev side. <br /> A <br /> Signed 21� <br /> Title: Date: <br /> t' FOR DEPARTMENT USE ONLY <br /> Application Accepted by CA Irk <br /> Date Area <br /> Pit or inspection b ate Final In <br /> J <br /> spection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83548385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 .� <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO SH RECEIVED BY DATE PERMIT''NO. f <br /> + EH 13-24(REV.1/8 5) =;26 <br /> EH 14-28 � /yi <br />