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}, APPLICATION FOR PERMIT — _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _ 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (� , <br /> 0-� <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 r <br /> Local Health District. <br /> Job Addres.10 VnJF2 6 h '"-5:3_ City MaWLot Size lmk4wPM <br /> Owner's Nam.7 Address � & _AU ,- Phone O <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP:. ti 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 RICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE I J TYPE OF WELL PROBLEM A A CONS UCTION SPECIFICATIONS <br /> ❑ Industrial 3❑ Open Bottom El Manteca Di of Well Excavation Dia. of Well Casing <br /> CQ Domestic/Private ❑-,Gravet Pack , Ll Tracy pe of Casing Specifications x <br /> f'1 Public f 1'Other -, 171 pelta De of Grout Seal Type of Grout _ <br /> I I Irrigation =Approx. Depth I I Eastern Surfac Seal Installed by <br /> Repair Work Done 17 ?Type of Pump P. State Work Done <br /> i <br /> Well Destruction ❑ Well Diameter; Sealing Material Itop 50'1 <br /> d Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION l 1 DESTRUCTION (No septic system permitted if public sewer is-- <br /> available <br /> s-available within 200.feet.) <br /> installation will serve: Resid nce * Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a'de Wof 3 feet: Water table depth �'1 <br /> SEPTIC TANK ❑ Type7Mf.g- "' Capacity No. Compartments <br /> PKG, TREATMENT PLT.-O f Method of Disposal <br /> Distance to nearest: Well Foundation Property Line N <br /> 3 3 <br /> LEACHING LINE ❑ Na:& Length of lines Total length/sire l r <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line. 3 <br /> SEEPAGE PITS i I­Depth 1 t Size Number { <br /> SUMPS d -Ll Distance to`nearest: Well FoundationProperty Line <br /> DISPOSAL PONDS ❑ <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 /> Home owner or licensed agent's signature.Zertifies 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." Coritractor s hiring or sub-contracting signature n <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 Califor <br /> The applicant c forrall equi ens. Complete drawing on reverse side. k� ~ <br /> Signed X ' Title: ��' <br /> pate: <br /> f <br /> ' FORD A ENT USE ONLY <br /> Application Accepted by Datea <br /> ea <br /> t frrc7� r <br /> Pit or Grout Inspection by } �' � D Final Inspection by pate <br /> Additional Comments: t j <br /> ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20N, Stk., CA 95201 <br /> FEE <br /> L INFO AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE f'PERMIT'NO. <br /> I <br /> +.EH 13-24(REV.1/95) s 4/7 <br /> EH 1426 ° .. �-/ Cl � <br />