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APPLICATION FOR PERMIT <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) p^ <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 S <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 /> ,f <br /> Job Address City Lot Size_44: A490 pM <br /> Owner's Name <br /> Phone <br /> Contractor's Name 4edem4f,1121 S641SLicense No. Phone 1yV — " <br /> 7J <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Cly <br /> PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER ❑ [" <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE Z <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial If Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other 11 Delta Depth of Grout Sea! <br /> ElIrrigation A Type of Grout <br /> � <br /> Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ "Well_Diametgr� ' <br /> _Sealing.Material-(top 50')._ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTAL EIREPAIR/ADDITION D DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> �// <br /> Installation will serve: Residence— Commercial_ Other available within 200 feet.) <br /> Number of living units:_/— Number of bedrooms Z + <br /> Character of soil to a depth of 3 feet: L Water table depth 4 <br /> SEPTIC TANK ❑ Type/Mfg r'" Capacity jNo:Compartments <br /> PKG. TREATMENT PLT. O <br /> s Method of Disposal <br /> Distance to nearest: Well Foundation <br /> Property Line <br /> L <br /> LEACHING LINE . ` <br /> Ero"N.. r?, Length of lines total length/size a. " <br /> FILTER BED ❑ Distance to nearest: Well ZL5 ' Foundation _ property Line <br /> SEEPAGE PITS Leo'Depth 2 J— ,_Size , <br /> Number i <br /> SUMPS ❑ Distance to nearest: Well`,(Fouridation ZO Property Line <br /> DISPOSAL PONDS ❑ 4. <br /> 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: "Pcertify thavin'the performance of the work for which this permit is issued, f 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 applican call for all required inspec'ons. Complete drawing on reverse side. <br /> Signed Title: <br /> Date: <br /> FOR PARTMENT USE ONLY <br /> Application Accepted by DateA <br /> — � _ WY <br /> rea <br /> Pit or Grout Inspection by = [�' Date Final Inspection by � <br /> Date l <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3821 ❑ Manteca 823-7104, EITracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 C <br /> FEE AMOUNT DUE AMOUNT REMITTED . CK 0 <br /> INFO 3 CASH RECEIVED BY DATE�Sv LJ C t <br /> PERMIT"N0. <br /> +EH 13.24(REV.10/93) - ` t� _ J '��� <br /> EH 1426 � �ll "'� <br />