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-7 �- 1 <br /> \APPLICATION FOR PERMIT <br /> SAN JOAOUIN-LOCAL"HEALTH DISTRICT <br /> • ' <br /> 1601 E. HAZE'�T©N�AVE,� STOCKTON, CA <br /> 'Telephone"•(209'466-6781' <br /> PERMIT EXPIRES 1 YEAR FR�M'DATE ISSUED <br /> (Complete`in Triplicate) <br /> District for a permit to construct and/or install the work herein described- This application is <br /> Application is hereby made to the San Joaquin Local Health <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. 1 <br /> yam'; a .A 73 `4 <br /> Job Address A. +✓ %' sc�Ci a PM z <br /> Owner's Name M�'�'S ►^!DyN\X35#ftas ne <br /> J } ! ` l License Na{ ` Phone S <br /> Contractor ddress <br /> TYPE OF WELL/PUMP: 1%-NEW WELL ❑ _ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 11 <br /> is PUMP INSTALLATION ❑ SYSTEM REPAIR �� -. OTHER ❑ <br /> DISTANCE TO NEAREST{ SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP..LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Indu ❑ Open Bottom -1Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 01� omestic/Private ❑.Gravel Pack 171Tracy Type of Casing Specifications <br /> [I Public El Other f Ll Delta Depth of Grout Seal Type of Grout ! <br /> ❑ Irrigation ��ppro>l. Depth' ❑ EEastern Surface Seal Installed by <br /> Repair Work Done ❑hype of Pun;p; H.P. State Work Done r <br /> Well Destruction ❑. .Well Diameter Sealing Material (top 501 w <br /> Depth Filler Material (Below 501 <br /> i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system <br /> permitted if public sewer is <br /> Installation will serve: Residence i� Commercial_ Other <br /> Number of living units: Number of bedrooms l <br /> 1 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t <br /> PKC. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING UNE -❑ No. &Length'of fines - -V " " Total length/size <br /> I FILTER BED OJ-bitance_t ,neares[' WeIII Foundation Property.Line <br /> SEEPAGE PITS ❑ Depth ' - Size i Number <br /> SUMPS �" '❑ Distance to nearest: oil! Foundation Property Line <br /> DISPOSAL P;ONpS i ❑ <br /> CF- . <br /> I hereby certify that i have piepareqi this}application,and that the<work`will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and redulati`Rs-4fjfFat.- .' jbaquin.Local-Health D' ''t. <br /> Home owner til enseq agent's si ture certifies t oil wing: cierflfy that in the performance of the work for which this permit is issued, I shall not <br /> employ an pergonrin such manneea to become s Jett to work &ompen tion laws of California."Contractor's hiring or sub contracting signature <br /> certifies t of ollowipg certify that' t � perfo nce of 1 for ich t permit is issued, I shall employ persons subject to workman's compensa <br /> tion la of Kalifornia." <br /> The app an must II f e i d ins pe i t dra g on re arse <br /> Signed' t Date <br /> �' �-•r---�-'--t: - FOR DEPARTMENT USE ONLY ��" �"� "----�*---• -� <br /> Application Accepted by: '- Date Area <br /> ti <br /> Pit or Grout Inspection by t Date 'Firial Inspection by �—�+- Date <br /> Additional Comments: { z <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 /> FEEAMOUNT DUE AMOUNT.REMITTED CASH RECEIVED BY-` DATE T. PERMIT''NO. <br /> INFO' <br /> {L3 + EH 13-241REV.1/86) <br /> EH 1426 <br />