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APPLICATION FOR PERMIT y� <br /> # SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Teiephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED '. <br /> { (Complete in Triplicate) . <br /> Application is heieby 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. <br /> ! r <br /> Job Address --7sn 9 f/ouj Lot Size PM <br /> Owner's Name lQ('�y� Address Phone <br /> �! � r <br /> Contractgr, raff—e Address Pt>--11-3 pic License No. r�` Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUI;TION^�L7= 3 <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 /> k. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wel! Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other o ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ----4pprox/-k <br /> Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter'! Sealing Material (top 50') <br /> __.Depth.. — L--- .-Filler Material-{Below 501--•-- - �f <br /> TYPE OF SEPTIC-WORK;.-NEW INSTALLATION '� REPAIR/ADDI-TION ❑1' DESTRUCTION E] (No septic system Perm itted;if public sewer is � <br /> r r available within 200 feet i;+, 1 <br /> Instaliationkwill serve: , Residence. Commercial-=e Other <br /> Number oi,living u s:- i Number of bedrooms <br /> i- f <br /> Character of soil to a depth of 3 feet: f1 /} , y Water table depth <br /> SEPTIC TANK ,t Type/Mfg l 71.i� qr,1 LrY"1::.r" Capacity l, No. Compartments <br /> PKG. TREATMENT PLT. F1 j: i . Method of Dis c�a! 4' <br /> Distance to nearest: Well ?fFOuri1dation f Property Line <br /> e <br /> P'# r F1:, <br /> LEACHING LINE P""No. & Length of lines ; X i4i TPi:al length/size _ I <br /> FILTER BED . ❑5 Distance to,.nearest: .Well- '-Foundation Property Line <br /> SEEPAGE PATS' ❑' Depth ri - Size s Number <br /> SUMPS f7 Distance to nearest- Well Foundation 1 Property Line <br /> DISPOSAL PONDS ❑; r <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules an&regulations of the°San Joaquin Local Health District. <br /> Home owner,orlicensed agent's-signature certifies the"folld ing: "I"certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any pe?son in such manner as td become subject to workman's compensation laws of;California." Contractor's hiring or sub-contracting signature <br /> certifies the fgllowirig:"I certify that in th a performance of the work fo`r which this permit is issued, I shall employ persons subject to workman's compensa- - _ ji <br /> tion laws of California.'; '^- <br /> The applicant must call for required inspections. Complete drawing on reverse side. j <br /> . <br /> Signed X � -101401L Title: ! Date: s <br /> y.}=. 1 <br /> FPR DEPARTMENT USE ONLY <br /> Application Accepted by (Date Area Q <br /> t T. I k <br /> Pit or Grout Inspection by Date Final Inspectign by Dated ! <br /> Additional Comments: f x <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-;,6385 <br /> Ap 6iicant - Return all copies to: Environmental Health Permit/Services-1601-E-Hazelton�Av., P.O. Box 2009, 5ik., CA 95201 i <br /> IFEE <br /> NFO AMOUNT DUE, AMOUNTREMITTED CAH- RECEIVED BY•^,;- _,.,.DAT,__ PERMIT NO. <br /> t <br /> + EH 13-24 IREV.1/115) <br /> — �`"•-�... % �••. 1 b q�C1 I <br /> EH 14-25 i - - <br />