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APPLICATION FOR PERMIT \ � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA $p, <br /> Telephone 1209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED 04 <br /> i (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,T� t i 3hon is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulatiotib� Joaquin <br /> Local Health District. <br /> f <br /> Job AddressCity r Lot Size PM <br /> III <br /> Owner's Name Address Phone <br /> _ Gy <br /> Contractors O -�-�' � �address d 0_$43L <br /> 43Lictinse Ko. yz Phon <br /> TYPE OF WELL/PUMP: u NEW WELL C WELL'REPLACEMENT ❑ DESTRUCTION C <br /> PUMP INSTALLATION C SYSTEM REPAIR}X,, OTHER ❑ <br /> —DISTANCE-TO NEAREST: SEPTIC-TANK,. .SEWER LINESDISPOSAL FLD.. ,. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> industrial C Open Bottom 11Manteca Dia. of Well Excavation Dia. of Well Casing <br /> I_omestic/Private G Gfavel Pack ❑Tracy Type of Casing Specifications <br /> �„ <br /> ("� Public C' Other n Delta Depth of Grout Seal Type of Grout--. <br /> I ' Irrigation _11Approx, Depth I I Eastern Surface Seal Installed by - <br /> Repair Work Done Type of P.ump __. H.PState Work Done <br /> Well Destruction C WeII1Diameter ��_ __. Seating Material (top 50') " <br /> W Depi ,_ Filler Material (Below 501 <br /> . "{TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I 1 INo septic system permitted it public sewer is <br /> I'll available within 204 feet.) <br /> Installationwill serve: Residence Commercial_ Other <br /> l Number of living units: Number of bedrooms ' x �i <br /> Character oftsoil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK` LiType/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ �I '�, Method of Disposal <br /> i <br /> Distance to'riesrest; Well T Foundation Property Line Q <br /> LEACHING LINE O No. & Length of lines ' Total length/size <br /> r <br /> FILTER BED ❑ Distance to nearest: Welt. Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> 'i SUMPS Ll 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 /> j 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, I shalt 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 /> 1 certifies the following:"I certify:.thst 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." II, <br /> The applicant mu rSr all required in ctions. Complete drawing on r verse side. <br /> Signed t Trt } Dater <br /> R DEPA TM USE ONLY <br /> Application Accepted by II, Date -Area! �� <br /> pP , <br /> Pit or Grout Inspection byIII. Date Final Inspection by ate <br /> 9IAdditional Comments: — <br /> ❑ Stk 465-6781 C Lodi: 369-3621 ❑ Manteca 82.3-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies tot Environmental Health Permit/Services 1641 E. Hazelton Ave., P.O. Box 2009, Stk_ CA 95201 <br /> -FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT NO. <br /> 'INFO f O CASH <br /> EH 13-24 IREV. <br /> EH 1426 <br /> ill <br />