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APPLICATION.FOR PERMIT <br /> # <br /> 1: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 Tripiicate) = i <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 Rules and Regulations of the San Joaquin <br /> Local Health District: <br /> CIA— <br /> Job Address / ?e.F &12 �n ���` Z CityLot Size PM <br /> Owner's Name ddress y Phone <br /> s <br /> Cnntractorwz5orn W�`j dress License No. ' g` Phone 3 0 <br /> TYPE OF WELL/PUMP: NEW WELL WELL_R.EPLAUE ENT ❑ DESTRUCTION ❑ <br /> a <br /> # �jiroS 5 UMP INSTALLATIONC �_� SYSTEM R PAIR ❑ OTHER ❑ <br /> 4 DISTANCE TO NEAREST: EPTIC TANKt r�°X SEWER LINES' DISPOSAL FL D.; t PROP. LINE <br /> { <br /> FOUNDATION:- RICULTURE WELL OTHER WELL PITS/SUMPS : <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUClON SPECIFICATIONS Y <br /> l ❑ Industrial C�7+ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> pp Dia. of Well Casing <br /> }a Domestic/Private Gravel Pack ❑ T rah Type of Casi 1, 5. Y Specifications <br /> ❑ Public Ocher I ❑ belta � Depth of Gro t Seal Type of Grout <br /> L3 Irrigation pprox. Depth C] Eastern Surface Seal Installed by <br /> l Repair Work Done ❑ +pe of Pump H. .4' State Work Die <br /> Well Destruction ❑ ell Diameter Sealing at <br /> Merial (top ) <br /> epth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑L REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is <br /> available 6 ithin 200 feet.l <br /> Installation will serve: Residence Commercil_ Other f <br /> Number of living units: I Number of bedrooms <br /> Character of soil to a depth of 3 feet: t - Water t sble depth _ <br /> SEPTIC TANK ❑ Type/Mfg , Capacity Not,Co partments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line [~� <br /> LEACHING LINE 1711 No. & Lerfgth of lines f F Total length/size{ 7s� ' <br /> FILTER BED LJ Distance to nearest: ' Well Foundation Property Line 5 <br /> F SEEPAGE PITS ❑' Depth i Size Number <br /> SUMPS ❑ Distance to nearest: , Well Foundation Property U66 T <br /> DISPOSAL PONDS ❑ <br /> k I hereby certify that I have prepared this application and that the work will be donerin accordance with San J4aqui3 county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. I <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the wor for ich this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Cont acto�s hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this per'mit is issued, I shall emplo per ns subject to workman's compensa- <br /> tion laws of California." I 6 <br /> The applicant must calI r all required inspections. Complete drawing on revers side. <br /> i flZ. <br /> Signed Xyfl "' Title:' f k- i Date: <br /> i FOR DEPIRTMENT USE ONLY f� I <br /> \( `—� Date _4' Z p Area <br /> Application Accepted by 1�1�Ai - <br /> 7- �- ' - �d <br /> , Pit or Grout Inspection by � r { Date � Final Inspection by Date moi <br /> Additional Comments: <br /> Stk 466-6781 ❑ Ldd! 369-3621 4 _0 Manteca-823-7104 - ❑-Tracy 835-6385 <br /> pplicant - Return all copies,to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 20091 Stk CA 95201 <br /> T FEE <br /> 'AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO +' �_...,.,.„.,.� <br /> + EH13-24 SREV.1/8 51 <br /> 4-26 <br /> EH 1 <br /> { _._ <br />