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APPLICATION FOR PERMIT NmOo <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA , <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (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 Rifles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address <br /> n City `12.2 0 Lot Size IA--D L PM <br /> Owner's Name .t U 5iC, AddressHQQA;a�r_ L+] C, Y,= 4ti <br /> - Phan <br /> Contract OGG3�?�-k-Tce .-4ti—Address f �1 ,a c�n �r,ucr0 cense No. `t3 t3`l3Phone( 1� L- It 23Y- ) <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D3.I { <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r� <br /> L1 lndustnal ❑ Open Bottom O Manteca Dia. of Well Excavation.. .++-rti Dia. of Well Casing C <br /> Ll Domestic/Private 5[Gravel Pack 0 Tracy Type of Casing Specifications <br /> ❑ Public C1 Other ❑ Delta Depth of Grout Seal >✓ t--'r Type of Grout =me-T VVV <br /> I_' Irrigation CLApprox. Depth C1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth <br /> Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION FJ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <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. ❑ Method of Disposal <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 /> 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, 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 applic ust call for 11 re r <br /> Inspections. Complete drawing on reverse side. <br /> Signed Title: 4/u���i >+S i +1, <br /> � Date: <br /> D ONLY <br /> Application Accepted b Date .= 7�"'Area Zf <br /> Pit r Grout i9is ti y D to,,5 Final 3n ^miction by I Ad Date �� 7 <br /> Additional Comments: <br /> Q:�5& 466-6781 0 L i 369 1 ❑ Manteca 823-7104 ❑ Tracy 835-6385 - <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 AMOUNT REMITTED <br /> INFO _ CASH RECEIVED BY GATE PERMIVNO. <br /> • EH 1324 01Lv �- <br /> EH 1426 �� ' v�./ ✓> � <br />