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4 <br /> fir. ✓ . <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. i <br /> �(f f � i <br /> Job Address .2 2 K b CityZe_ ize & PM <br /> .Owner's Name A 4411 11 AIM Address _/X)6961�Z�Phone '� 3 1 <br /> 5 7'r2 0;3,I <br /> Contractor Mft,6MdS 5!Kddr,_ss License No. Phone r <br /> TYPE OF WELL/PUMP: NEW WELL JX WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION'Ir SYSTEM REPAIR ❑ OTHER ❑ 4- j <br /> DISTANCE TO NEAREST: SEPTIC TANK 1> SEWER LINES DISPOSAL FLO. PROP. LINE ♦�U `^ I <br /> FOUNDATION _ (�_..__.._._ AGRICULTURE WELL — OTHER WELL •� PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION <br /> ❑ Industrial ElOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> jDomestic/Private 'Gravel Pack ❑ Tracy Type of Casing Specifications eL <br /> 1-1 Public f 1 OPer H Delta Depth of Grout Seal Type of Grout 17 )ZF i <br /> I 1 Irrigation _Approx. Depth t I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump fdJE!2 H.P. '2– State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> �1 TYPE OF SEPTIC WORK: NEW.INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION ( I (No septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence— Commercial_ Other p _ <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> ` SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments l7 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal Q <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size ' <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size Number <br /> \}J SUMPS ❑ Distance tD nearest: Well foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 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 /> Theapplica:!;�ui s. Complete drawing on re a seside. <br /> Signed X = Tit[e: V,66 Date: <br /> FOR DEPARTMENT USE 6NLY <br /> Application Accepted byf\ 6. Date �� Area 1 <br /> Pit or rou spectiontw-'w _rv�h� Date�lG�� Final Inspection bh^ _ Date <br /> Additional Comments: (41615b1r <br /> ❑ Stk 466-6781 ❑ Lodi 369 1 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED CK 4 CASH <br /> RECEIVED BY DATE PERMIT*NO. <br /> INFO <br /> r.EH 1324IREV.I/A5) 1D� .p-D r C <br /> EH 14-2e ( <br />