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APPLICATION FOR PERMIT <br /> 4 <br /> SAN JOQQUIN LOCAL HEALTH,DISTRICT' <br /> 1 t <br /> 1601 E. HAZElTON AVE., STOCKTON, GA a <br /> Telephone (209) 466-6781 <br /> l� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED A <br /> t (Complete in.Triplicate) <br /> Application is he+eby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is t� <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage-ar'No. 1862 for welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. - Y <br /> t <br /> Job Address / � .__ City Lot Size PM <br /> Owner's Nam <br /> 2 Address ?,62:5-:5- ���4 J r l're- Q/&one 41F `r JI <br /> ► GrJ _3Z <br /> ContractorS Address -« License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 1 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER © <br /> DISTANCE TO NEAREST: SEPTIC TANK /GY + SEWER LINES �' DISPOSAL FLD� PROP. LINE ��v f <br /> + FOUNDATION 3D AGRICULTURE WELL �- OTHER WELL � PITS/SUMPS <br /> I <br /> INTENDEb USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> � / ; <br /> Domestic/Private Gravel Pack ❑ Tracy Type of Casing k\ cifications _. "`' �} <br /> ❑ Public # (7 Other ❑ Delta Depth of Grout-Seal Type of Grout_ <br /> I I Irrigation 2_594prox. Depth I I Eastern Surface Seal Ins a)fed by $ /A/8SV 5_ <br /> Repair Work Done ❑ Type of Pump H-P. $tate`Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material ltop 501 1 ,�f " f <br /> Depth Filler Material (Below 501 —_ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION t I DESTRUCTION i I (No septic system permiitea if.public sewer is <br /> f available within 200 feet.) <br /> l ,i <br /> Installationwill serve: Residence— Commercial_ Other <br /> Number of,living units: Number of bedrooms 1 a I <br /> Character of soil to a depth of 3 feet: Water table depth Y <br /> SEPTIC TANK ❑ Type/Mfg I Capacity € No. Compartments <br /> PKG. TREATMENT PLT. El Method of Disposal t <br /> Distance to nearest: Well Foundation Property Line 1 <br /> LEACHING CINE ❑ No. & Length of lines Total length7size� <br /> FILTER BED( EI Distance to nearest: Well Foundation 4i_..Property Line _ <br /> f EES PAGE PTS V) Depth Size cs.1 Number j <br /> 'SUMPS Cl Distance to neatest: .t�Well -~"Foundation property Line lit( <br /> ,DISPOSAL PONDS ❑ I �,y'fJ.��c- 1 1 <br /> ).hereby certify that I have prepared this application and thaVthe work will be donet in accStr ah'cWw_ ith 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 irr b _peffpr_manee of_the_work,torswhich thi"Vrmitsissr'e',1I shall not 3 <br /> employ any person in such manner as to become subject to workman's compensation laws of Califbmia." Contractor's hiring r sub-contracting signature I <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 mc aired ' Comp leta`draw ing on revs elide. I <br /> I Signed X Title: Date: n IF <br /> FOR DEPARTMENT US ONLY <br /> pplication Accepted by Date 'Z9 Area <br /> r <br /> pj <br /> i <br /> Pit or Grout,Inspection by Data a1 Final Inspection by /I'�i fate <br /> 1 I <br /> Additional.Comments:- <br /> __L:_S1k_-.466-6781- . __ L1.todi---369-362-1 --- ©-Manteca--a23-7104'--�Z=-^ Tracy--835=63$5-------�--- —' <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 3 <br /> FEE AMOUNT DUE _tAMOU T REMAITTED' T~CASH 4 RECEIVED BYDATE PERMIT IVO. <br /> INFO E <br /> + EH 13241REV.I/A5) �jfy <br /> EH t4-26 1 <br /> f <br />