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it <br /> E <br /> APPLICATION FOR PERMIT <br /> SAN JOAdUIN LOCAL'HEALTH DISTRICT <br /> 4 1601 E. HAZELTON AVE., STOCKTON, CA <br /> 1 Telephone (209) 466-5781 <br /> e <br /> PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED'At, 1 <br /> F }I1 {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. This.application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of.the San Joaquin <br /> Local Health District. <br /> Job Address ! City 'Lot Size ''i`= } }„ - <br /> '3e PM <br /> it <br /> Owner's Namef Address - <br /> Phone A29112-4 <br /> Contractor a/�lC 'L�i 4ddres4 1 - � <br /> c cense No. Phone 2 LY <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> .ii PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER.*' <br /> _ DISTANCE TO',NEAREST: SEPTIC TANK SEWER LINES _, DISPOSAL FL_O. PROP. LINE_ <br /> FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS <br /> -��,.,,q <br /> INTENDEDJUSE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />{ ❑ Industrial I ❑ Open Bottom ❑ Manteca Dia. of WeILfExcavation Dia. of Well Casing <br />{ *Domestic/Pr,ivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation 0 _�4pprox. Depth El Eastern Surface Seal Installed by <br /> Repair Work Done X Type of Pump H.P.-L. 1 _ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') _mod <br /> i Depth Filler Material (Below 501 ( LA <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ i,DESTRUCTION ❑ -(No septic system permitted if public sewer is <br /> 16 'available within 200 feet.) <br /> installation will serve: Residence_ Commercial— Other <br /> Number of liking units: Number of bedrooms " " ` ' --- Y 4— <br /> Character <br /> —Character of soil to a depth of 3 feet- <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity= i No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation"_ Property Line <br /> LEACHING LINE ❑ No. & Length of lines ` <br /> 9 Notal length/size <br /> FILTER BED IE ❑ Distance to nearest: Well -Foundation 1?yoperty Line <br /> SEEPAGE PITS. ❑ Depth 1 Size 1 Number. f <br /> SUMPS , - ❑_Distance to nearest: Well Foundation __ Property Line ,�. <br /> �. _ <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. r s <br /> Home owner or 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 lawsof California." <br /> Thea applicant mut call far a uired ins <br /> PP q inspections. Complete drawing on rev a side. <br /> L r �.- <br /> Signed Title: <br /> Date: <br /> II / OR DEPARTMUSE ONLY / <br /> Application Accepted by ��/ Date s S� 7'2 Are <br /> a <br /> Pit or Grout Insyl I <br /> pection byAIIDate Final 1 spection by f L Dates <br /> Additional Comments: <br /> rr� <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 t <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 -' <br /> • _.l <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIY'N0, <br /> INFO 1 <br /> + EH 1324IREV.1/851 11 �ZZ! <br /> • EH 1426 �S� �O S�,O / g�%�6 <br /> i <br />