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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781- i <br /> S PERMIT EXPIRES 11YEAR'FROM DATE ISSUED' 7. <br /> ' h'` "`' <br /> ` (Complete in Triplicate) <br /> V� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descrlbed.,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. <br /> Job Address Q �P City `r 5 Lot Size ! * t. �� PM <br /> C41 Cd /( <br /> Owner's Name /1 Address 1/��i t Phone = <br /> r <br /> �J t License No,(, - p <br /> Contract J - Address )0 %`O -7 Li'64 r�oZ�P Phohe <br /> TYPE OF WELL/PUMP: NEW WELL-❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION'❑ SYSTEM REPAIR ❑ OTHER ❑ $. , <br /> DISTANCE TO NEAREST: SEPTIC TANK !Z SEWER LINES 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. r+O Tracy Type of Casing I[Specifications I <br /> ❑ Public ❑ Other ' o,❑ Delta Depth of Grout Seal Type of Grout O <br /> ❑ Irrigation --Approx. Depih 41O'E4stern Surface Seat Installed by I <br /> Repair Work Done ❑ Type of Pump r+ a i_ H.P. State Work Done 6 <br /> Well Destruction ❑ Well Diameter .1 �"- Sealing Material Stop 501 ; <br /> Depth L' Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION;❑ 'REPAIR/ADDITION_ —_—P..ESTRU-CTION-I] (No septic system permitted if public sewer is <br /> � ! t" available within 200 feet.) <br /> Installation will serve: Residence 'Commercial`! Other <br /> Number of living units: Number of edroo s 1 <br /> Character of soil to a d7epth of 3 feet"' Water table depth / G <br /> SEPTIC TANK "•l1ETType/Mfg Capacity/,Q No. Compartments r <br /> PKG. TREATMENT PLT. ❑" :4 � i fMethod of Di. oral <br /> r. <br /> Dista cn e-to nearest:_�_­Weti—1570 Foundation, Property Line <br /> LEACHING LINE CK No. K Length'of kine Total length/size <br /> 1 FILTER BED ❑ Dim nce to nearest: Well Foundation RC1 Property Line �S <br /> I SEEPAGE PITS ❑ Depth �` * Size �r �X 11� =Number <br /> 4 SUMPS F Distance to nearest: Well `br Foundation 16 Property Line <br /> f DISPOSAL PONDS ❑ "" <br /> 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. t <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 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." sj <br /> The applicant m t call for all re fired inspections. Complete drawing on reverse side. <br /> Signed Title: V �. Date:'. <br /> FOR DEPARTMENT USE ONLY <br /> Im 1 �4,11 , 1 &T ( <br /> � fr` <br /> Ap 'cation Accepted by Date Area <br /> or Grout In§pection by , !' DateJ � Final Inspection by !� Date <br /> Additional Comments: <br /> ❑ Stk 4664781 ❑ Lodi 369-3621 L Manteca 623-7104 ❑ Tracy 835-6385 I <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 f AMOUNT REMITTED CASH RECEIVED BY DATE. - PERMIT`NO. <br /> INFO _ <br /> + EH 13-24 iREV. <br /> EH 14-26 -Lis • d .� <br />