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APPLICATION FOR PERMIT k <br /> SAN JOAQUIN,LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 it <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> _ (Complete in Triplicate) <br /> Application is here h the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in complianSan quin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health rict. <br /> Job Addre c 1 <br /> ��` City Lot Size PM <br /> r� <br /> K 4., <br /> Owner. .Name. S '• if ress - ne• +� <br /> r § <br /> Contractor 117,04 Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS v'J <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> El Domestic/Private 11 Gravel Pack ❑ Tracy Type of Casingt'.r' <br /> Specifications <br /> .,-4uc �•-- C1-Other <br /> PbliEl Delta Depth of Grou;*Sea! <br /> ;Type of Grout <br /> p Irrigation �Approx. Depth ❑ Eastern Surface Seal InAalled by 'wf <br /> Repair Work-Done ❑ Type of Pump t H.,. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50')J,' °� ? <br /> Depth k <br /> Filter Material IBelow 501C-2 <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is <br /> ` x _ ailable within 200 feet.) <br /> Installation will serve Residence_ Commercial_ Other. <br /> .r .. -.� <br /> Number of living,units: Number of bedrooms -A, <br /> rCharacter of soil to a depth of 3 feet: .�'.° 3 . 1 �°��, � <br /> } , Water table depth <br /> r SEPTIC TANK/ 0 Type/Mfg '` Capacity No'Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> -if j,IV Method of Disposal <br /> Distance to nearest: Well 2. Foundation }Property Line <br /> LEACHING LINE 1 ❑ No. Il, Length of lines Total length/size <br /> FILTER BED El Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth <br /> r- Size Number e <br /> f <br /> SUMPS Distance to nearest: WellFoundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepaied 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 i <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:"!certify that in the performance of the work for which this permit is issued, I shall employ persons subject toworkman's compensa- <br /> tion laws of California." <br /> The applicant! for all required inspections. Complete drawing on reverse side. ' <br /> a <br /> Signed X <br /> Title: Date: <br /> ;FOR DE ARTMENT USE ONLY <br /> Application Accepted by +� � Date � Area O <br /> Pit or Grout Inspection byDat r Final Inspection by Date T�1' <br /> itional Comments: 1 /,/ <br /> ,12M& 466-6781- ❑.Lodi 359-3621 . .., ..❑ Manteca„823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601E.:Hazelton Ave., P.O. Box 2009, Stk- CA 95201 <br /> A.4ve- opc2— <br /> .. . <br /> ti ti.'f <br /> FEE <br /> INFO AM UNT DUE ` 'AMOUNT REMITTED RECEIVED BY DATE PERMIT ND. <br /> f <br /> + EH 18-24O 1REV.iiH5J 1 C3�'� L - Y - � <br /> EH 1428 i� � x-11—W <br />