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-fo APPLICATION FOR PERMIT <br /> SAN JOAQUIN,LOCAL HEALTH DISTRICT 6q <br /> ` 1601 E. HAZEL i ON AVE., STOCKTON,'CA �+-� �, t vc 4 Lc <br /> Telephone (209) 466-6781 41 U hc- <br /> I PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDy�,yt, g <br /> (Complete in Triplicate) laeaY�` �ird7 -�' m� <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. p Rules an <br /> 1862 for well/ and the d Regulaiions of the San Joaquin <br /> �� <br /> Local Health District.. .,`i <br /> b . � <br /> Job Address // _ �?R Lot Size 'If <br /> Q FIM <br /> Owner's Name Z// -� ! , <br /> ` ��" _L Address Phone ��S <br /> 7 <br /> Contractor .�- Address License No. Phone <br /> TYPE OF WELL/PUMP: v NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO _ TIC TANK,-�_____. SEWER LINES- ,DISPOSAL FLD. PROP. LINE <br /> FOUNDATIO AGRICULTURE WELL OTHER WELL. PITS/SUMPS 4 ' <br /> "INTENDED USE TYPE OF WELL PROBLEM AR RUCTION SPECIFICATIONS <br /> O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Exc <br /> 1:; Dia. of Well Casing <br /> ❑,.Domestic/Private ❑ Gravel Pack' ❑ Tracy Type of Casing k Speccations <br /> ❑ Public ❑ Other , ❑ Delta Depth of Grout Seal- y ' rout <br /> ❑.Irrigation �4pproz-Depth ❑ Eastern Surface Seal Installed by . <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter t <br /> Sealing Material (top 50') � <br /> t Depth Filler Material (Below 50') <br /> TYPE.OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION 0 {No septic system permitted ifpublic sewer is <br /> F ; available within 200 feet.) <br /> Installation will serve: Residence A'f' Commercial_ .Other �1 ,� . <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 Capacity No. Compartments/ <br /> PKG. TREATMENT PLT. ❑ <br /> t Method of Disposal <br /> Distance to nearest: Well Foundation ,00V. Property Line } <br /> I <br /> i <br /> LEACHING LINE ❑ No. & Length of lines. t Total length/size s <br /> FILTER BED ❑ Distance to nearest: Welt 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, 1 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 amploy persons subject to workman's compensa- <br /> tion laws-of California:" <br /> The applicant m II for all,required spections. Complete drawing on reverse side. <br /> Signed Title: <br /> y Date: <br /> i <br /> ,ERR DEPARTME NT USE ONLY I <br /> Application Accepted by �-� Date - _ <br /> �r Area <br /> Pit or Grout inspection by Date Final Inspection by Date 1, <br /> Additional Comments: / <br /> ❑ Stk 466-6781 ❑ Lodi 369-362f, ❑ Manteca 823-7104 ❑ Tracy ' <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I <br /> FEE-- AMOUNT DUE AMOUNT REMITTED <br /> INFO RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24{REV.1/s 51 - -1 <br /> E ` , �,... �^^/ <br /> EN 426 ��� __. `-'I <br />