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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> l 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> I 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 wail/pump and the Rules and Regulations of the San Joaquin r <br /> Local Health District. <br /> Job Address V�[ <br /> City u)Lot Siza e 7-1 P m <br /> Owner's Name 4_ -5L Address AIM IV • (m1EL Phone u <br /> nW �L r` �r <br /> ,Contractor's Name �!L1� � license No. � � tti9 13 Phone Zr <br /> TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT DESTRUCTION ❑ <br /> ` 1 PUMP INSTALLATIO �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 ff i j <br /> ❑ Industrial - ❑•Open Bottom,. -- ❑-Manteca -Dia..of.Well Excavation Dia. of Well Casing <br /> t <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing—' E` Specifications <br /> ❑ Public ; Other E] Delta Depth of Grout Seal Type of Grou <br /> El Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by <br /> AALC— <br /> Repair Work Done .. Tyl7e of-Pump H.P. E State Work Done <br /> �� ! estruc//t��ion Well-Diameter`! Sealing Material (top 501 ! <br /> C!'i Depth Filler Material (Below 501 d <br /> k TYPE OF SEPTIC WORKi NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if'public sewer is AA <br />€ g available within 200 feet.) 3 N k' <br /> InstaAation will serve: Residence Commercial y Other I <br /> 1-.+..�.....-.�.�..,. y F <br /> Number of living u6its: Nu'nlbe{of bedrooms t <br /> Character of soil to a depth of 3 feet-., ' Water table depth i <br /> SEPTIC TANK } f ❑~7yp�/Mfg Capacity 'No.Compartments �• <br /> PKG. TREATMENTPLT. ❑ / E Method of Disposal <br /> f s Distance to,nearest: Well Foundation Property Line ' <br /> LEACHING LINE _ &_Length of,line§ t Total length/size <br /> FILTER BED f �'[�;r gis§tapc%to nearest:,t Well Foundation ' Property Line 1. I <br /> r. �r '..r.� <br /> SEEPAGE PITS ❑ Depth Size Number [� -- <br /> SUMPS ❑ Distance to nearest:' Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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:."I certify that in the performance of the work for which this permit is issued, I shall not <br /> r employ jany ' n such manner as to become subject to workman's compensation laws of Caliifornia." Contractor's hiring or sub-contracting signature <br /> certifies :"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa-tion lawia."The appcall foIku <br /> i cti . Complete drawing on reverse side. <br /> i <br /> LY <br /> Signed Title: Date: 2� JA <br /> ..� FOR DEPARTMENT USE ONLY <br /> Application Accept od by Date 7- Area 10 2--Y <br /> (\� " <br /> 4 <br /> Pit or Grout Inspection by Date / incl Inspection by pate <br /> �Ad lona} Comments: ��� �-� d ��-• ���—�y �—���f-�- <br /> /0 5% 466-6781 ' ❑ Lodi 369-3621 Manteca 823-7104 ."D 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 /> 't t ry <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24(REV.V/83) <br /> EH W28 S5 y OO" _ / <br />