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�`r_-,F APPLICATION FOR PERMIT � ✓G � �.�, 1/ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> f <br /> ,PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y� <br /> (Complete in Triplicate) <br /> ` 1. <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 <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 Jop <br /> Local Health District. 11 <br /> Job Addressr'tii 2 ZZ V114 <br /> ��" CityRe—14'IVLS Lot Size_ ���� P`. <br /> Owner's Name UA%iIA]titsVtC# _ Address L Phone-3 <br /> Contractor Address License No. `Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHEFZ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LIN (34 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUh <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia" of Well Excavation Dia. of WF <br /> )(Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specificat„ <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grou. <br /> ❑ Irrigation / pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump a1 H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other 1 <br /> Number of living units: Number of bedrooms <br /> tj Character of soil to a depth of 3 feet: Water table depth ( <br /> SEPTIC TANK ❑ Type/Mfg i Capacity No. Compartments <br /> 1 PKG. TREATMENT PLT. E] 3 Method of Disposal <br /> ' / <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size "— <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> 1 SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ t <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, 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 applicant al a quir spections. mplete wing on reverse side. <br /> Signed Title: <br /> Date: .-_� '� _ <br /> FOR DE ART MENT <br /> USE ONLY pp l <br /> Application Accepted by �� Date L'— 4f Area ® } <br /> 4 <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: _ <br /> ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.0_ Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE - PERMI"T•NO. <br /> INFO <br /> + EH 13-24(REV, v / 6, -��1AM <br /> � . - <br /> EH 14.26 � � � � �? � �'. r� �/ ��r- I <br />