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t <br /> APPLICATION FOR PERMIT k <br /> SAN JOAQUIN`LOCAL HEALTH DISTRICT <br /> r 1601 E. HAZELTON'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. - l ;` <a," ' AP <br /> jr <br /> Job Address �ll�g TZ[ 7r � �- CiWg4V1r M Lot Size ' r' PM <br /> Owner's Name Address ,,Cf �J/, 441L��L�,��u'� - Phone — <br /> r <br /> Vw <br /> Contractor ` J fT Address`//, �� _R License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL. WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> g'Domestic/Private ❑ Gravel PackElTracy Type of Casing Specifications <br /> ❑ Public ❑ Other t J,C1 Delta j" ;Depth of Grout Seal Type of Grout <br /> 171 Irrigation +�Approx. Depth � �Eastern' Surface Seal Installed by n <br /> Repair Work Done ❑ Type of Pump 1114-aa�cl H.P. j State Work Done s <br /> WeIL Destruction , Cl.. Well Diameter Sealing Material (tap 50') F <br /> Ja , ,,� ^�'' ./•���;. .� "'*' y'. <br /> ► +,r y pt r -Filler Material (Below 50'1 I # <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑" REPAIR/ADDITION C3 DESTRUCTION Ll (No septic system permitted if public sewer is "! <br /> 5 r available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other ! <br /> Number of living units: Number of bedrooms <br /> �tharacter of soil to a depth of 3 feet: ! Water table depth <br /> SEPTIC TANK ❑ Type/Mfg . - Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ -ice Method of Disposal <br /> f.r <br /> Distance to nearest: Well Foundation Property Line 0 <br /> :I I <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 U <br /> SUMPS. ❑ =Distance to.nearest:_ Well Foundation," Property Line.-.- <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done 1670Gcordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. - :, `r 0 <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 laws of California." <br /> - <br /> The applicant ust call for all required ' ctions. Complete drawing on r rse side. <br /> Signed Title: C_utet,' Date: <br /> _ T USE ONLY <br /> FOR DEPART N ' <br /> Application Accepted by 1/ Date v fArea 0 �, <br /> Pit or Grout Inspection by Date Final Inspection by Aen " 'Date <br /> Additional Comments: ' - <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 , ❑ Manteca 623-7104 ❑ Tracy 835-6385 i <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. ,Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMO UNTDUE AMOUNT REMITTED C RECEIVED BY_ DATE PERMIT`NO. <br /> + EH 13-24(REV.t/65) .4 • <br /> EH 14-26 <br />