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5 <br /> APPLICATION FOR PERMIT <br /> N SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON,AVE., STOCKTON; CA <br /> Telephone (209) 466-6781 t <br /> i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r <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 Ryles and Regulations of the San <br /> Local Health District. > <br /> T D� . <br /> Job Address0 0 <br /> City'--ha-6A Lot"Size , PM <br /> Owner's Name P Address ^~ <br /> Phone <br /> Contractor } <br /> Address- .2 License m -02 08/ti Phone <br /> TYPE OF WELL/PUMP: IV NEW WEL WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑� SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 7-�f PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL—Q—&5 PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation . / <br /> Dia. of Well Casing <br /> Domestic/Private I Gravel Pack 'Tracy Type of Casing_. Pm, Specifications , <br /> ❑ Public ❑ Other LJ Delta Depth of Grout Seal <br /> �; Type of G out <br /> El Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by t <br /> Repair Work Done ❑ Type'`of,Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material {top 50'1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is <br /> available within 2 feet.) { <br /> Installation will serve: Residence_ Commercial, ,Other - /� � i <br /> Number of living units: ii Number of bedrooms �p. 1 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Ca act <br /> p tY No. Compartments , <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line } <br /> ;i I <br /> LEACHING LINE ❑ Na. & Length of lines Total length/size k <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number r <br /> SUMPS ❑ Distance to nearest: Well Foundation1 k <br /> DISPOSAL PONDS ❑ ,� Property Line <br /> I 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 /> )' 1 I <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of <br /> employ any person in such manner as to become subject to workman's comthe work for which this permit is issued, I shall not <br /> certifiespensation laws of California.",Contractors hiring or sub-contracting signature I <br /> the following: "I certify that in the performance of the work for which thisermit is issued,I shall employ p P Y persons subject to workman's compensa- <br /> tion laws of California." <br /> The a �jl <br /> pp'c t must call for req ' d inspections. Complete drawing o reverse side. , <br /> Signed ! <br /> .� Title: F Date: <br /> FOR DEPART E USE ONLY <br /> Application b <br /> Accepted <br /> p Y Date Cs' rU Area (•� <br /> Pit or Grout Inspection by,. <br /> Date Final'l Inspection by Date <br /> � / ' <br /> Additional Comments: � ' r ;� ' <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 b ❑ Manteca 823-7144 ❑ Tracy 835-6385 "' <br /> Applicant- Return all copies to: Environmental yklyealth Permit/Services 1601 E.'Hazelton Ave., P.O.1/Box 2009, Stk., CA 95241 <br /> �) ..FEE <br /> CV.. <br /> NFO AMOUNVDUE AMOUNT REMITTED K " <br /> CASH { RECEIVED BY �DATE PERM11-.11 - <br /> EH 13-24(REV.3/95) <br /> EH 1426 =1-21 <br />