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4111 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEILTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 . . ,. .n <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> x , (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 Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> �]J k:' <br /> Job Address �/�� �� l �Z`�1��►'I f City Lot Size PM <br /> Address Sn --� Phone {- <br /> y{Y:,tis,Owner's,Name �.j, - <br /> ict r 32 VZ 7--(e Phone, <br /> Contractor' � Address � � License No.. <br /> TYPE OF WELL-/PUMP:- -..NEW-WELL-Q----- --WELL-REPLACEMENT❑- —DESTRUCTION-0- <br /> PUMP <br /> DESTRUCTION-❑-PUMP INSTALLATION ❑ SYSTEM REPAIR;❑; _, OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER'LINES'' l t` ' ` DISPOSAL FLD. PROP. LINE <br /> EIL7 <br /> �"°" �� FOUNDATION AGRICULTURE WELL OTHER WELL PITSI5UMP5 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom = Manteca Dia. of Well Excavation Dia. of Well Casing (\ <br /> I ❑ Domestic/Private El Gravel Pack. <br /> ❑ Tracy' Type o Calling Specifications 1\ \T <br /> p ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> i <br /> © Irrigation ---Approx. Depth ❑ Eastern --Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.Pr9[! ._ - '-f State Work Done <br /> I' Well Destruction ❑ Well Diameter Sealing Material (top 501, <br /> Depth Filler Material.(Below 50'1' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EPAIR ADDITION DESTRUCTION ❑ (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:-I— Number of be ooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> -u <br /> I SEPTIC TANK ❑ Type/Mfg capacity-L No. Compartments <br /> f PKG. TREATMENT PLT. 0 <br /> �1 Method of Disposal <br /> c Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE -# 'U�-No. & Length of lines. <br /> Total length/size / K <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line .5 <br /> SEEPAGE PITS Depth rIS- Size Number <br /> SUMPS ❑ Distance to nearest: Well M6• Foundation //3 P 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 agents 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 /> w s <br /> The applicant must call for all required inspections. Complete drawing on reversepside. <br /> Signed Title: �� i. Date: a <br /> l r <br /> FOR DEPARTMENT USE ONLY DI <br /> I Application Accepted by F Date 5d, P Area Z� �� <br /> Pit or Grout inspection byP DateX/?JFinal Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-8385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services IBM E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> INFO �y <br /> + EH1324{aEV.i/b5) Ca y 0� <br /> EH 1426 <br />