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�4 APPLICATION FOR PERMIT <br /> �-i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEILiON AVE., STOCKTON, CA <br /> FtTelephone (209) 466-6781 <br /> . PERMIT EXPIRES 7-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. 7 f <br /> F11 <br /> Job Address / �J/ 4 _ ' <br /> /�/J rtvl r Lot Size pM <br /> Owner's Nam �f7�vLQ, /!L( 'j2Ell1 Address Phone <br /> F Contracto PA Address r ense <br /> 7 LicNo.�b , w Phone, %O <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMINT ❑ DESTRUCTION 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES <br /> DISPOSAL FLO. PROP- LINE <br /> FOUNDATI04 AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 0 DomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1.I Irrigation <br /> Pigation Cl Other n Delta Depth of Grout Seal Type of 1�out <br /> L _.Approx- Depth I I Eastern Surface Seat Installed by <br /> E Repair Work Done L3 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> F-1 Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION V_t- PAIR/A ITION I DESTRUCTION I I INo septic system ✓ <br /> � " , r A permitted i! public sewer is U <br /> available within 200 feet.) <br /> FInstallation will serve. Residence— Comer rel Ot Number of living units: —/— Number of badrooms <br /> Character of soil to a depth of 3 feet: Water table depth f <br /> SEPTIC TANK i Type/Mfg 425,: CapacityNo. Compartments <br /> i PKG. TREATMENT PLT.. ❑ i. Method of Disposal <br /> Well r <br /> v. Distance to nearest: Wel _ Foundation_ PropertyLine_�_ <br /> LEACHING LINENo. 8 Length of lines Total length/size <br /> `t ' FILTER BED C1Distance to nearest: Well Foundation Property Line <br /> I <br /> SEEPAGE PITSDepth Size NumberIX <br /> SUMPS ` <br /> j !<7 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 /> r 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 ojAub-contracting signature <br /> certifies the following:"f 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." i <br /> The applicant ust call f 11 r wired inspections. Complete drawing on revers s-de: <br /> Signed XTitle: ✓, Date: <br /> FOR DEPARTMENT.USE ONLY <br /> Application Accepted by Date "' y Area <br /> C. r Grout Inspection by Date ,'�uFina! Inspection by J0Date __ _L <br /> 1 <br /> GGG I Additional Comments: <br /> ❑ Stk 466-6181 ❑ Lodi 369-3621 ❑ 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 /> FEE AMOUNT ptfE AMOUNT REMITTED CK RECEIVED BY DATE PEitMtl7 hrO. <br /> INFO CASH <br /> ♦.EH 13-24IHEV.irn5) —7c) Z <br /> FEN14-26 <br /> I <br />