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� o s <br /> APPLICATION FOR PERMIT 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ��1lyT <br /> 1601 E..HAZELTON AVE., STOCKTON, CA P P11 fD I <br /> Telephone (209) 466-6781 R <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED O� �`r✓ �9a <br /> v (Complete in Triplicate) AL HtiALJH <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work here aWn is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules ��11 %w an Joaquin <br /> Local Health District.: » <br /> f X o2S7 J PM <br /> Job Address r % e s City Lot Size 2S7 <br /> 00 <br /> Owner's Name Address v Phone g� T <br /> r <br /> Contractor Address Q�F License No. 1-;Y?o 813 Phone <br /> TYPE OF WELL/PUMP: U NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D <br /> DISTANCE TO NEAREST: 'SEPTIC TANK O"P. SEWER LINES DISPOSAL FLD. nOrA" PROP. LINE <br /> _ - FOUNDATION AGRICULTURE WELL OTHER WELL PITSLSUMPS-,—.__ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private Gravel Pack Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal �� z Type of out <br /> ❑ Irrigation __�_4pprox. 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 <br /> Depth � � Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Install atiqi will serve: Residence— Commercial— -Other ' <br /> r <br /> Number of livin s: Number of bedrooms <br /> Character of soil to a dept t: Water table depth (� <br /> SEPTIC TANK ❑ Type/Mfg f Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Fou Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total leng <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> i 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 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 Cal'ornia." <br /> The appli st call for.all requir d ' spections. Compll drawing o ev rse side. <br /> Signed 1.409nr Date: <br /> FO DEPAR ENI USE ONLY <br /> Applicationccepted by Date Area <br /> Pit or rout I spection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMITNO. <br /> INFO <br /> + EH14-24IREV.i/e51 ­7 S-21�� , 67 <br /> EH 14.2$ <br />