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:f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 4 <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ,7 (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 <br /> Local Health District. AZA <br /> . y. ' <br /> Job Address k; City Lot Size PM <br /> Owner's Name Address'- Phone <br /> Contractor's Name z/�t7�" s License No. � Phone <br /> r TYPE OF WELL/PUMP:- C1, NEW.WELI�--Q =: WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> �,. PUMP INSTALLATION Q ;'SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 'SEWER LINES - - DISPOSAL FLD. PROP. LINE <br /> I 1' �• FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL -PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial ,❑ Open Bottom ❑ Manteca Dia. of Well Fitcovation Dia. of Well Casing <br /> ❑ Domestic/Private ❑.Gravel Pack �❑ Tracy `�. _Type of Casing �" Specifications <br /> Q Public �❑ Other )❑ Delta _ Depth*f Grout Seal ype of Grout <br /> ❑ Irrigation "12—LApprox. Depth ❑ Eastern Surface Seal Installed by iA " <br /> Repair Work Done ❑ e of Pump '` IH:P. ; State Work Done t <br /> Well Destruction ❑ Well Diameter v > Sealing Material (top 50'1 <br /> i 3 <br /> Depth �J-�. :Filler)Material (Below 501 ' <br /> TYPE OF SEPTIC.WORK: NEW INSTALLATION`0- :REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is ��oo <br /> •$, ,. available withih-200 feet.) e7 <br /> � Installatiori will serve: Residence_ Commercial <br /> Number of'living units: Number ofdrooms - , <br /> Character of soil to a depth of 3 feet: - Water table depth <br /> SEPTIC TANK I ❑ Type/Mfg apacity 1pz2o No. Compartments - <br /> PKG. TREATMENT PLT.❑ tr V _Method of�Disposal 5 <br /> Distance to;nearest* Well .� Foundation f 4' 0 Property Line To <br /> LEACHING LINE ength;of lines f tY �' Total length/size <br /> FILTER BED ❑ Distance to'nearest: Well Foundation " Vrroperty Line R <br /> 1 <br /> SEEPAGE PITS ❑ Depths Sizey `Number <br /> SUMPS ❑Distance to nearest: Well Fotfnedation "Property Line .,,. <br /> DISPOSAL PONDS ❑ 41 <br /> hereby certify that I have prepared this applicailon and that the,wiprk willi,be,d_one in,accordaynce with San Joaquin county ordinances, state laws, and <br /> Lo <br /> rules and regulations of the San Joaquin cal 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'wdrkman's compensation`laws of California."-Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of-thework for which this permit is.issued,1 shall employ personsubj <br /> sect to workman's compensa- <br /> tion laws of California." f� -P <br /> The applicant m call for all required inspectionsyomplete,drawing on reverse sid E',% <br /> Signed Title: _'Date: Zee A�2 <br /> FOR DEPARTMENT USE ONLY '} 4 <br /> # tJ�F/�- D `�`^ � - <br /> ,Application Accepted byt- `:: ate Are <br /> Dat"e- Final Ins ction b Date <br /> ,Pit or..Grout Inspection by p Y <br /> Additional Comments: <br /> D Stk 466-6781` O Lalli^3W3621 ❑ Manteca 823.7104 11 Tracy"835-6 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P:O Box 2009, Stk., CA 95201 <br /> ' a1. FEE AMOUNT DUE Am6UNt REMITTED CASH RECEIVED BY 'DATE PERMIT': 0. ° <br /> INFO _ <br /> +EH 13.24[REV.10!63! '•"` � �//"'2�,� D <br /> EH 14-26 <br />