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f e <br /> APPLICATION FOR PERMIT I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephohe (209) 466-6781 <br /> t PERMIT EXPIRES i 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. 1862forwell/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address v a City G Lot Size <br /> PM <br /> Owner's Name Address Phone <br /> Contractor 1— T1�_ 4�L_ Address �P0 t8_Or �" License No.a-7 C�_Phone 7 <br /> TYPE.OF WELL/PUMP: _NEW WELL ❑­ WELLREPLACEMENT ❑ DESTRUC710N�❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP- LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> i _ <br /> j INTENDED USE r TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS- <br /> 4 ❑ Industrial f ❑ Open Bottom LJManteca Dia. of Well Excavation Dia. of Well Casing <br /> i 1:1 Domestic/Private , ElGravel Pack ❑ Tracy Type of Casing Specifications <br /> j1 Public ❑ Other C1 Delta Depth of Grout Seal A Type of Grout <br /> rApprox. Depth I Eas[ern - .. Surface Seal Installed by - <br /> 1 I I Irrigation . <br /> t <br /> Repair Work Done ❑ Type_Gf Pump_---- w_H.P• -- .w -- _ State Work Done <br /> Well ibestruction ❑ Well Diameter Sealing Material (top 501 <br /> ! <br /> t Depth Filler Material (Below 50'! <br /> ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I <br /> REPAIR/ADDITION DESTRUCTION 1 I (No septic system permitted if public sewer is <br /> available within 200 feet.) N <br /> a <br /> -� „installation will serve: Residence— ommercial <br /> 3 . <br /> _x Number of living units: i Number of bedroo <br /> Character of soil to a depth of 3 feet: Ja ° Water table depth <br />{ SEPTIC TANK ❑i Type/Mfg — Capacity J No. Compartments <br /> PKG.' TREATMENT PLT. ❑ Method of Disposal <br /> 'Distance to nearest:' Well '--Foundation Foundation Property Line ' <br /> LEACHING LINE t V--No. & Length of lines ��,}y- TSV lelength/si <br /> ze <br /> o FILTER BED : ; r ❑ Distance to nearest: Well Edi- Found"ation_ �L— Property Line <br /> SEEPAGE PITS l 1 Depih ' Size f Number <br /> SUMPS ii� Distance to nearest: Well ;rdS f1 Foundation �Jt , Property Line <br /> DISPOSAL PONDS ❑ f <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 liceKsed ageni's nidi 6iure'certifies the following: "I certify that in the-performance of-the work for which this permit is issued, I shall not <br /> employ any pefson 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'taws of California." ti <br /> The applican�must �forpu �inspecttonscor�npleterawing on reverse side. <br /> Signed X_ Title: Date: <br /> a f-FO Et ARTMENT USE ONLY <br /> {{ Application Accepted by Date Area <br /> I _ Date�'� 3_�'f`.� .�. <br /> 11 Pit or Grout Inspection by y Date Final Inspection.by <br /> . tit w J k 'n <br /> ' Additional Comments: , - <br /> ( ❑ Stk 466-6781 [ Loai,369-3621' ❑ Manteca ta23-7104 ❑ Tracy 835-6385 <br /> Applicant- Retuen ail.copies`'to:Erivironniental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 'FEE, AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> +.EH 13-24 MEV. �� <br /> y EH 14-2e <br /> r <br />