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J :�r <br /> F APPLICATIOWFOR PERMIT 1 <br /> f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> l 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> 4 Telephone (209) 466-6781 a <br /> Y 2 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> �l (Complete in Triplicate) ENVIROMENTAL HEALTH <br /> bavdR+R06$Iication is <br /> l Applicatioh is he!eby made to the San Joaquin Local Health District for a permit to construct and/or install the work-hFrWi <br /> k 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. t <br /> 11 � ' <br /> ! <br /> Job Address �144City Lot Size PM <br /> Owner's Name t2 A4 4440 Address to 114 Z Phoner� <br /> Contracto W ML,417 Address / nse Ko, Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLZ-AiO <br /> ON SYST THER ❑ <br /> 'DISTANCE TO NEA-REST:�SEPTICTANKSEWER-LINES t <br /> DISPOSAL FED. PROP. LINE' <br /> �i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ In trialpen Bottom ­E] Manteca Dia.-of Well Excav m - `' Dia. of Well Casing <br /> 5— <br /> P-Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public Cl Other {71 Delta Depth of Grout Seal Type of Grout <br /> tI I I Irrigation �_Approx. Dept { I Eastern Surface al Installed by ' <br /> 1 5 — <br /> Repair Work Done ❑ Type of Pump H.P. State Work Do e <br /> Well Destruction (Weil Diameter _ Sealing Material Itop 50') € 6 <br /> 3 Depth 1 � r Filler Material (Below 50') ! <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION i I DESTRUCTION f I (No septic system permitted if public sewer is <br /> available within 200 feet.I . <br /> Installation �ill serve: Residence Commercial_ Other x <br /> Number of living units: ' Number of bedrooms <br /> Character of soil to a depth of 3 feet: Jr �' r Water table depth 4 <br /> �. <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ �W `Y Method of Disposal <br /> ► Distance to nearest: Well ' Foundatio Property Line <br /> LEACHING LINE ❑ No: & Length of lines __ ' Ib I Total length/size ` I <br /> FILTER BED ❑ Distarice to nearest: Well F Foundation Property Line, <br /> F <br /> SEEPAGE, <br /> _Size IDepth ' 'Size t Number <br /> SUMPS ❑ Distance to nearest: Well Foundation ' *) Property Line f <br /> DISPOSAL PONDS ❑ <br /> i I hereby dertify 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 /> f 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 Calif rnia." <br /> The applicant u call for all re i d ins tions. Complete drawing on rr rse side <br /> Signed X Title: _�/ '_�( ! Date: �� <br /> FOR DEPARTMENT USE ONLY <br /> �� <br /> � Application Accepted by Da G Area <br /> yr <br /> Pit or Grout Inspection by Da `a !nal Inspe innsDate' <br /> 1 <br /> Additional Comments: -WO / ¢ 2. �++ e <br /> ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 /tel <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., Cifr95201�f. <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO; f <br /> n <br /> INFO CASH <br /> + EH 13.24{REV.! H5) <br /> EH 14-26 / <br />