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•r <br /> w APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> 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 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 forawell/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Lam` <br /> Job Address City, I�Lot Size_�0> *&W PM' <br /> tf <br /> Owner's Nam _ d' dress <br /> dS � f��C�Phone <br /> /� LicenseNp` fs^rte b 7 <br /> F Contractor's Name � �`� Phon � -`S �r <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE=S.,. DISPOSAL FLD. PROP. LINE <br /> { <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial Q Open Bottom ❑ Manteca .Dia. of Well`Excavation Dia. of Well Casing <br /> Q Domestic/Private ❑ Gravel Pack ❑ Tracy Type of'Casing Specifications <br /> D Public ❑ Other ❑ Delta" Depth of;Grout Seal Type of Grout <br /> © Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H. `' State Work Done <br /> f Weli Destruction ❑ Well Diameter Sealing Material (top 50')W �� <br /> Depth Fifler-Material.(Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION ❑ DESTRUCTION ❑ (No 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 <br /> Character of soil to a depth-of 3 feet:. -" Water table depth <br /> ' <br /> SEPTIC TANK hype/Mfg Capacity ' No. Compartments <br /> PKG. TREATMENT PLT.❑ " �r Method of Disposal <br /> Distance to nearest: Aell F �ndation Property Line <br /> LEACHING LINE .LD No. & Length of lines " © ljolbo, Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line_� C <br /> SEEPAGE PITS Depths_ / _size r f <br /> Nyrllber <br /> SUMPS <br /> ❑ Distance to nearest: WeltFoupdation Property Line <br /> DISPOSAL PONDS ❑ 1l - <br /> Cd,� c <br /> I hereby certify that I have prepared this application and that the work wffl be doe in accordance with Sa Joaquin county ordinances, state laws, and <br /> r rules and regulations of the San Joaquin Local Health District.._ T' <br /> I Home owner or licensed agent's signature certifies the following:r"1`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 appli nt`m call for l wired inspections. Complete drawing.on._reverse side.. <br /> Signed <br /> • Title: _ Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area o2L <br /> Pit or Grout Inspection by ate Final Inspection by Date <br /> Additional Comments: ��-�' � :° . 7 3;7 3'7 73• <br /> ❑"Stk 466-6781 ❑,Lodi 369-3621 ❑ Manteca` 82317104 I` ©;Tracy 6.6385 <br /> Applicant–Return all copies to: Environmental Health Permit/Services 1601 E: Hazelton Ave.; P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT`DUE AMOUNT REMITTED CK RECEIVED BY <br /> INFO CASH DATE PERMIT`NO. <br /> J EH 13-24(REV-10/83) <br /> FH t42B �' 1 �� �5Q �•��a� <br />