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i <br /> APPLICATION FOR PERMIT <br /> I. SAN JOAQUIN"`LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ONµAVE., STOCKTON, CA <br /> Telephone (209)-466-6781 <br /> i PERMIT EXPIRES,VYEAR FROM DATE ISSUED ;' <br /> (Complete'in y.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 Ryles and Regulations of the San Joaquin <br /> 'Local Health District. 5-x <br /> Job Address <br /> Lat Size J-Q PM, <br /> Owner's Name -Address Z.Z j F id. } <br /> y! )) Phone <br /> Contractor_���/ /9F/�B�' <br /> Address License No. p�4+z6�—7024 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ -SYSTEM REPAIR ❑ OTHER E, <br /> DISTANCE TO NEAREST: SEPTIC TANK"Y"EWER LINES DISPOSAL FLD. PROP. LINE- <br /> , FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS f <br /> ❑ Industrial I❑ Open Bottom ❑ Manteca Dia. of Well ExcavationZ� <br /> VI Dia. of Wel! Casing � <br /> X Domestic/Private ❑ Gravel Pack t .�„ ❑ Tracy Type of Casing C Specifications <br /> ❑ Public 'Other ,� ❑ Delta Depth of Grout Seal ycp Type of Grout Bh1700Jt1Mt t <br /> ❑ Irrigation __14prcx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Wo Done <br /> Well Destruction LJ Well Diameter° Sealing Material {top 50'1 t/'5-' Et <br /> Depth Filler Material (Below 50') 6-L1X- Ad <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> y available within 200 feet,i <br /> Installation will serve: Residence t r-Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: r Water table depth <br /> SEPTIC TANK ❑ "Type/Mfg 'Capacity-r Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Wel! Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> k SUMPS ❑ Distance to nearest: Well Poundation Property Line <br /> DISPOSAL PONDS �. 11r - — <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquih county ordinances, state laws, and , <br /> rules and regulations of the San Joaquin Local Health District. I <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, l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side.+> t <br /> SignedTitle:=—t_..,µ��__S -. _ Date: AS <br /> arG w rtirAftiYlC� 531 ij . <br /> F RDE DEPARTMENT USE'f1NLY <br /> Application Accepted by Date <br /> Ira <br /> Are,' Z <br /> ♦ t Pit or Grout fnspe Io yate Final Inspection by Date <br /> Additional Comme <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Ma teca 823-7 G4 ❑ Tracy 8355-6385 � <br /> 'Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO RECEIVED BY . DATE PERMIT"NO. r <br /> + EH 13-24(REV.1/8 5) _ ! �d <br /> EH 1428 3,w -7 q/ 1/ eS <br />