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I! •' <br /> ' APPLICATION FOR PERMIT <br /> f SAN JOAQUIN LOCAL HEALTH DISTRICT f <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> F <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> / <br /> (Complete in Triplicate) �r <br /> I <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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address <br /> 1h.: i✓ City I^ Lot Size PM <br /> Owner's Name �- r s�6 !r?O7.S 1_ Address <br /> �l1 Il Address ��CJ�' r �'> /License IVo.Q(gCg33Phone-?, QL7 <br /> Contractor , <br /> TYPE OF'WELL/P11MP: 'NEW'WEL'L�---WEL-L REPLACEMENT ❑-- 1)ESTRUCT4GN_[;1 r=-�-_-ti-_­_ <br /> PUMP INSTALLATION >r- SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC .TANK _ .-.� SEWER LINES DISPOSAL FLD. PROP. LINE Q <br /> FOUNDATION -j-e2__ AGRICULTURE WELL OTHER WELL ` PITS/SUMPSP <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial Wopen Bottom .❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 'DomesticlPrivate L-1 Gravel Pack 17 Tracy Type of Casing, 5pecificafions <br /> M Public (7 Other C1 Delta Depth of Grout Seal z Type of rout c SLG <br /> I k Irrigation 1a2-50Approx. Depth I Eastern �u ace Seal Installed by - b <br /> Repair Work Done ❑ Typelh-t Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50') <br /> ,I <br /> Depth Filler Material {Below 501 y` <br /> TYPE OF SEPTIC WORK: NEW <br /> INSTALLATION I I REPAIR/ADDITION ! I DESTRUCTION I I (No septic system permitted if public sewer is. <br /> i available within 200 feet.) <br /> i <br /> Installation will serve: Residence_ Commercial— Other ' { <br /> 1 <br /> s Number of living units: " Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water`table depth N <br /> SEPTIC TANK ❑ Type/Mfg " '" Capacity No. Compartments , t�tp1 <br /> PKG. TREATMENT PLT. ❑ I� «-•rte=- - .� _.,.-�+ Method of Disposal I <br /> Distance to neatest: Well Foundation Property i. <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I l Depth Size Number <br /> SUMPS l-1 Distance to nearest: Well Foundation Property Line c <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 /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's'signature certifies the fallowing: "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 i <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." ILII 5 <br /> The applicant must call for all required inspectionsr Complete drawing on reverse side. <br /> Signed u "IL� Title: - f Date: t <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by __. _ Date 1 Area ` 4 <br /> Pit r Graut ns ctian b Date �\ U iZ- <br /> pe <br /> y SA Final Inspection by )w` S Date <br /> Additional—Comments:" <br /> ❑ Stk 466-6781 ❑ Lodi; 369-3621 ElManteca 823-7104 LlTracy 835-6385 <br /> Applicant - Return all copies to�:` Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009;'Stk., CA 95201 <br /> N <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY <br /> INFO DATE PERMiT'ND. <br /> +.EH 1324 IREV.I/K 5) <br /> EF1 11-26 <br />