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9 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ��'�3�s�`l` <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 /> n described.This <br /> cation is <br /> made in(compliance with SanoJoaquthe in County Ordinance n Joaquin lNto. 549 for sewage or h District for a permit <br /> No. 1662 for cwen/pump install <br /> nd the Rules and IR Regulations of he San l Joaquin <br /> Local Health District. <br /> �y ,,// c�-r,o <br /> Job Address a s� New ` V ) city `J/� 4A�Cot Size PM <br /> Owner's Name{, t7 .Z AT Address �s� )e—u �`y , `� Phone <br /> Contractor Address License No. _ Phone <br /> TYPE OF WELL/PUMP: NEW WELL n WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 ❑ Tracy Type of Casing Specifications <br /> F1 Public n Other n Delta Depth of Grout Seal Type of Grout <br /> n <br /> I I Irrigation —Approx. Depth I I 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 . Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I I (Noseptic with200 rmiit1ed if public sewer is <br /> available Installation will e: Residence_ Commercial_ Other (;.f <br /> Number of living units. Number of bedrooms C <br /> Character of soil to a depth o feet: r table depth C <br /> SEPTIC TANK ❑ Type/ Ca No. Compartments C( <br /> 1 Method of Disposal \ <br /> PKG. TREATMENT PLT. ❑ - <br /> Distance to nearest: Foundation Property Line <br /> LEACHING LINE ❑ ength of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundab Property Line <br /> SEEPAGE PITS I I 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 applicant njust call for all required inspections. Complete drawing on reverse side. <br /> Signed X_��71.fI An T OM �-7C�i`[ir �,X.f./.f�P� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspecti <br /> Date Final Inspection by Date �Z <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl Manteca 623-7104 ❑ Tracy 635-6365 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk.,.CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> . EH 13-24(REV.r/s sl `� ' iZs `� �l <br /> EH 1M2a <br />