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APPLICATION FOR PERMIT rC ° <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT V, ray <br /> 1601 E. HAZELTON AVE., STOCKTON, CA Pt8 <br /> Telephone 42091 466-6781 SA J~ <br /> N 98 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �0A <br /> (Complete in Triplicate) ��ALTHp !TLoPAt, <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. TFi�s'rpplication 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. gS33Zj 0 <br /> ,� rr Fl <br /> Job Address �W. � � w`�-e;� Lot Size PM <br /> Owner's Name Address OCO one — 57-;46 <br /> Contractor's Name License No. Phone 53/,5—&A577 <br /> TYPE OF WELL/PUMP; EW WELL. WELL REPLACEMENT Or DESTRUCTION ❑ <br /> PUMP INSTALLATION�❑I SYSTEM REPAIR ElOTHER ElDISTANCE TO NEAREST: SEPTIC TANK 10 SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL -- OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom X Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private `Gravel Pack ❑ Tracy Type of Casing oe Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of t 1! <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by 0 <br /> J, Repair,Work Done ❑ Type of Pump H.P. State Work Done W <br /> 6 Well Destruction—Z6, Well Diameter Sealing Material (top 50') <br /> wDepth Filler Material {Below 501 <br /> \ _ ., _ YPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms V <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal r' <br /> Distance to nearest: Well Foundation Property Line <br /> 7 <br /> LEACHING LINE ❑ No. 8a Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line . <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 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—r4ust call for all ruir spections. Complete drawing on reverse si <br /> ?k, <br /> Date: <br /> Signed. Title: c. <br /> FOR DEPARTMENT USE ONLY rr <br /> Application Accepted by Date Z Area ©b <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ odi 369-3621 Manteca 823-7104 Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental H alth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNTREMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> + EH W26IREV.10!831 <br />