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I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON' CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> ]Local <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 /> Health District. <br /> Job Address city Lot Size PM <br /> i Owner's Name _. U-'E b h f _ jT �7 Address Phone B 5 <br /> T Contractor 1061<e ,,00 <br /> �;✓'7 rw Address. License No. - fl-Ap Phone <br /> �NYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ <br /> I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> (;DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />' q FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL fi- PROBLEM AREA - <br /> CONSTRUCTION SPECIFICATIONS <br /> I❑ Industrial ❑ Open Bottom, ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> E,❑ Domestic/Private ElGravel Pack ❑ Tracy Type of Casing Specifications <br /> 0 Public ❑ Other ❑ Delta-- -,-.. i Depth of;Grout Seal Type of Grout <br /> _}❑ Irrigation —Approx. Depth ❑ Eastern `'Surface Seal Installed by <br /> Repair Work pone ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501) <br /> I Depth Filler Material (Below 501 <br /> ,TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence= Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a dept f 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> ! rMethod of Disposal <br /> . <br /> j. Distance to nearest: xWell Foundation Property Line <br /> ,4 <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Wel! Foundation Property Line <br /> li a <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> l: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 /> ton laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed Title: * f _ Date: A - 9-/ <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Data Area <br /> I <br /> P]it or Grout Inspectionb Date Final Inspection by +r p —Z <br /> Additional Comments <br /> z/ v �b � <br /> O Stk 466 67$1 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. e <br /> i <br /> + EH 13-24(REV. <br /> EH 1428 r7� Gc9 <br /> E, Z5 <br /> E� i <br />