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APPLICATION FOR RERMIT _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' 1601 E_ HAZELTON AVE., S OCKTON, CA <br /> r 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 HeaM 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. 18E2 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address &o 1Z__(&V9,',RAJ_4,,VCi, _ZG,9J Lot Size Ply <br /> Owner's Name Address /2z-/ <br /> hone 6/� YS`77o <br /> r r 3 <br /> Contractor ! wAddress K t '" 1 License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Al t4jdt-1 11& <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE SO <br /> FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS _ . A <br /> INTENDED USE TYPE OF WELL PROBLEMAREA - CONSTRUCT/CN SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Ex avation 7 Dia. of Well Casing <br /> 'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing S-C-H i4c, VC Specifications 1 <br /> ❑ Public 'Other ❑ Delta Depth of Grout Seal Type of Grout <br /> r <br /> C�J7q.C.t <br /> ❑ Irrigation ---Approx. Depth ❑ Eastem Surface Seal In tailed by i <br /> ' <br /> Repair Work Done ❑ Type of Pump ��— H.P. <br /> tState W r Done a <br /> °. Well Destruction ED Well Diameter Z f' Sealing Material{top 50'1 E ENhA+ <br /> Depth Piller Material (Below 5011 Auc-c s <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DEST UCTION ❑ (No septic system permitted if public sewer is 0 <br /> available within 200 feet.] <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: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg <br /> Capacity No. Compartments ,F <br /> PKG. TREATMENT PLT. [I Method of Disposal <br /> Distance to nearest: <br /> Well Foundation Property Line W Tr <br /> LEACHING LINE ❑ No. & Length of lines Total length/size l <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> r <br /> SEEPAGE PITS ❑ Depth Sim Number <br /> SUMPS r ❑ 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 i <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the foflnwing: "I certify that in the rformance of the work for which this permit is issued, I sh1ill not <br /> employ any person in such manner as to become subject to workman's compensation laAts 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'subyect to workman's compensa- <br /> tion laws of California." <br /> The applic t st call for all required spec 'ons. Complete drawing on reverse side. <br /> Signed - =_, -- <br /> R c it .d1 pY.+i Date: <br /> w <br /> o►n} FOR DEPARTMENT USE NLY i <br /> Application Accepted by• J�,, Date 9 Area II <br /> Pit or Grout Inspection . Final Ins>ection by Date 4 — i <br /> Additional Comments: <br /> ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy <br /> Applicant - Return all copies to:'Environmental Health Permit/Services 1601 E. Hazeltoi Ave., P.O. Sox 2009, Stk., CA 95201 <br /> FEEt <br /> INFO AMOUNT DUE AMOUNT f;E1AI1TTE0RCXSI�lECEIVED BY DATE PERMIT"Np, <br /> 1u' f r <br /> + EH t3-24{REV.1/a 51 •7. �� c �L.. <br /> EH 14-26 V J <br />