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APPLICATION FOR PERMIT <br /> ': . SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I.1601 E. HAZELTON AVE., STOCKTON, CA O It *� <br /> Telephone {209) 466-6781 1� � <br /> PERM IT.=EXPIRES 7 YEAR FROM .DATE ISSUED-,,, <br /> (Complete in,Triplicate), ,�OME�`1S�Rv1C <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work. 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 andR ations of the San Joaquin <br /> Local Health District. '" - ..2 h <br /> .r <br /> Job Address 4' . ak € <br /> ., City Lot Size PM <br /> Owner's Name r" - ,-Address Pr - hone & .'L/ 1 <br /> �,,,GG�� I <br /> Contractor. t�G[.a l A dress P.O ! �Li ense No. z Phone�.�✓�ZZ� <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 f <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial E3 Open Bottom LJ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> G <br /> ><Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications \n <br /> ❑ Public ❑ Other r ❑ Delta Depth of Grout Seal Type of Grout (�\ <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump` H.P. State Work Done 114=4i 104"Irlllc <br /> Well Destruction ❑ Well Diameter ` Sealing Material (top 50'1- <br /> Depth I Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: :NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> t ; <br /> 'available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other . <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth ' <br /> SEPTIC TANK ❑ Type/Mfg Capacity `' - No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal d <br /> Distance to nearest: Well f Foundation Property Line + <br /> LEACHING LINE ❑ No. & Length of lines -€ A - Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation 4 Property Line <br /> SEEPAGE PITS ❑*N Depth Size Number <br /> SUMPS ❑ Distance to,}earesst:• Well - -Foundation� — Property-Line- <br /> t <br /> DISPOSAL PONDS ❑ +. •; '" <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 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 /> 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 /> The applicant m f r all required inspections. Gomplete drawing on Fever-se side. <br /> Signed Title: 1, ? Date: <br /> a EO DEPARTMENT USE ONLY'" ' <br /> Application Accepted by Date e721 Area I <br /> Pit or Grout Inspection ►. <br /> pe b y Date Final Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71d4 ❑ Tracy 835-6385 , <br /> Applicant- Return all copies to: Environmental Health Permit/Services. 1601 E. Hazelton Ave-, P.O. Box 2009, Stk., CA 95201 <br /> r r - <br /> I CK <br /> FEE <br /> INFO ,,AMOUNT-DUE AMOUNT REMITTED CASH RECEIVEDBY DATE PERMIT"NO. <br /> i <br /> + EH13-241REV.1/n 5) /� <br /> 7 �j ' <br /> EH 1428 �� r U dam' '�7—?/ d � f <br />