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41 q3 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ��J <br /> A EL T ON AVE. STOCKTON CA <br /> 1601 E. H Z t,.. <br /> Telephone (209) 466-6781 W <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUEDtt ,f ( �� <br /> (Complete in Triplicate) ENViROMENTAL HEALTH <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein 04011MAERWIMen 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. <br /> i <br /> Job Address CityS&M1Z0.21Z Lot Size PM <br /> Owner's Name` "`T' �' ;" z`' Address ✓ Phone/'7 <br /> Contractor <br /> Address�J `�`'� License No. 132.3 Phone7`� <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION-0 SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />' 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 Excavation Dia. of Well Casing <br /> R-Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> t"1 Public [D.Other 171 Delta F Depth of Grout Seal Type of Grout--- <br /> I <br /> rout _I Irrigation Approx. Dept -­I-)-Eastern- Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump N.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l'I REPAIRIADOITION l I DESTRUCTION I I (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> - Installation will serve: Residence_ CommerciaL Other <br /> Number of living units: Number of bedrooms i <br /> Character of soil to a depth of 3 feet: . Water table depth N <br /> SEPTIC TANK ❑ Type/Mfg ""- L=� Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ' '`f`--�- Method of Disposal <br /> Distance to nearest Well Foundation `Property-Line <br /> LEACHING LINE ❑ No. & Length of lutes Total length/size <br /> FILTER BED 1-1Distanceto nearest: Well r Foundation Property Line <br /> f <br /> SEEPAGE PITS 11 Depth + Size _ Number i <br /> -SUMPS - - - Ll -Distance.to-nearest: Well w . Foundation Property 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 S <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." f <br /> The applicant t c ll for all required inspections. Complete drawing on reverse side. J 1 <br /> Signed X 1^ -T It le: Dater <br /> ff FOR DEPARTMENT USE ONLY <br /> Application Accepted by 1�1 l� _- Date q � Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> -ApYStk 466-6781 ElLodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> plicant - 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 CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> + EH 13-24(REV.1/95) - <br /> EH 14-26 //{ <br />