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APPLICATION FOR PERMIT „ n4 ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone {209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> {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 /> a a a City <br /> Job Address __ � � � __ � "�' Lot Size PM <br /> Owner's Name L)t &-AAddress r Phone �"i <br /> S — ND91Address PfioneContractori j 17 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ may` <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR © OTHER ❑ _ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 4 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom CJ Manteca Dia. of Well Excavation Dia. of Well Casing Q <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications j <br /> FI Public Cl Other F1 Delta Depth of Grout Seal Type of Grout <br /> I I irrigation —.Approx. Depth I I Eastern Surface Seal Installed by <br /> i <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ I <br /> ,Well-Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material {Below 50'i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIRIADDITION ! ESTRUCTION iRl (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence C mmerdial_ Other` <br /> 1 ' <br /> Number of living units: Number of bedrooms _ <br /> Character of soil to a depth of 3 feet: �1�I� R1i T Water table depth <br /> SEPTIC TANK ❑ Type/Mfg t Capacity No. Compartments _ <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> R Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE L —Ntf& Length of lines 5 Total length/size !� <br /> FILTER BED ❑ Distance to nearest: Well F undation� Property Line_.r. _ <br /> F <br /> I - <br /> SEEPAGE PITS I I Depth Size r Number <br /> SUMPS b-�-�Istance to nearest: Well Foundation �? Property Line <br /> DISPOSAL PONDS ❑ "J- <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 Pa w f Califorryi ' <br /> T applican If t call fuNall r uiredspecti ete drawing on r�arse sid <br /> Signed Title: ff, Date: r <br /> � x <br /> ` <br /> FOR RTMENT USE ONLY <br /> Application Accepted by , Date 1 o)70^ov Area O <br /> rrr�� p <br /> Pit or Grout Inspection by Date ' Final.Inspection by .Date 0 0 <br /> Additional Comments: Jr!-�X 'i.-,C�YtriLQiCQ <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE h tirINFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24 f REV.t/H5) <br /> EH lI-2B V <br />