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I - <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone {209} 466-5781 <br /> t PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) 209— 3ev - <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 nd the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address <br /> City <br /> (, Lot Size pM <br /> Owner's Name Address `' '�O. oee-* - I! Phone <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL y <br /> • �, WELL REPLACEMENT ❑ DESTRUCTION ❑ € <br /> PUMP INSTALLATION ❑ --e-, U SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES t DISPOSAL FLD. PROP. LINE <br /> FOUNDATION --AGRICULTURE WELL OTHER WELL PETS UMPS I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIO�NPOEIFICATI NS 1❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Ec <br /> 'a. of Well Casing <br /> ❑ Domestic/Private Gravel Pack Tracy - Type of Casing <br /> Imo; <br /> 9 Spec cations ` <br /> Public ❑ Other ❑ Delta _ _ _Depth of Grout Seal T (� <br /> ype of_Grout <br /> ❑ Irrigation a7 Approx. Depth ❑ Eastern Surface Seal Installed by - <br /> Repair Work Done_ ❑ Type of Pump H.P. State Work Done a <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50'1 0 (- <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION D DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.h <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms _ C' <br /> 1%) <br /> Character of soil to a depth of 3 feet: ' .� f Water table depth = <br /> SEPTIC TANK ❑ Type/Mfg [ r �V. Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ F ✓' <br /> Method of Disposal <br /> Distance to nearest: Y 5r Well Foundation Property Line. (� a <br /> LEACHING LINE ❑ No. & Length of lines ' .` Total length/size <br /> FILTER BED D Distance to nearest:r Well Foundation PrkopertyLine t <br /> SEEPAGE PITS ❑ Depth I Size' c' Number i <br /> SUMPS D Distance to nearest:"` 1Well -_ Foundation Property Line <br /> DISPOSAL.PONDS ❑ ,.` <br /> will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the work k <br /> rules and regulations of the San Joaquin Local Health District. ` <br /> Home owner or licensed agent's signature certifies the following: I <br /> employ an "I certify that in�the performance of the work for which this permit is issued, I shall not <br /> p Y y persons'n such manner as to become subject to lnrorkman's compensation laws of California."Contractor's hiring or sub contracting signature <br /> certifies the follow' g:"1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa f <br /> tion laws of alif rnia . <br /> The apia ica st call for all uir i s ions. Comple drawing on reverse side. . <br /> Signed4 Title: / <br /> Date: t <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ? �� <br /> Area <br /> Pit or Grout Inspection by Dates Final Inspection by Date <br /> Additional Comments: 3� <br /> ❑ Stk 466-6781 ❑ L i 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635 6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE D "�. <br /> INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br />' +EN 13-24 1REV.191831 <br /> EH 1426 Ic_7SS /�7 <br /> } <br />