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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT-,.',, <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA 4 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complet in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora Ormit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewag or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District" 21"uLu 5' <br /> i` <br /> Job Address F� �� r�r if f� � City S��X010 of Size 7-3-�?(100 PM <br /> Owner's Name Address <br /> Contracto Address 9.3o ae.,-2r-ceaG License No.5%y-�095­ <br /> Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK `°t SEWER LINES4. e ` A "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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ 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 PumpA H.P. State Work Done <br /> Well Destruction ❑ Well Diameter '" ' Sealing Material (top 50') <br /> Depth I Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is' <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Otherr <br /> Number of living units: Number of bedrooms ,t _ •� -1 <br /> Character of soil to a depth of 3 feet: _ J •Water table depth <br /> SEPTIC TANK i ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ?` * Method of Disposal <br /> Distance to nearest: Well Foundation I Property Line <br /> LEACHING LINE } ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation f Property Line l <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby certiN 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 foi-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 mus call for all req inspections" m te,drawing on reverse side. _f <br /> Signed X } { - Title/.`�[ss2�/ yI" l vr_ Date: <br /> a FOR DEPARTMENT USE ONLY ( \ <br /> Applicat"ioriA epted by Ar <br /> - `A' .> t 1�F ,r Date + � Z �� �' ' ea O <br /> A _ �— <br /> Pit or Grout Inspection bye Dat .Final I spection by ' "Date <br /> r <br /> Additional Comments: <br /> ❑ Stk 466-6781 Lodi 369-3621 . ❑ Manteca'/823` - . ._❑ 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 /> V <br /> INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY ryDATE <br /> ��'j/-yP7;�A;7Y <br /> PERMIT• <br /> EH14-24fREV.iiys7 ' cJ/ r1.� Y / <br /> EH t4-Z8� cJJ �(,�/ <br />