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4 <br /> .� APPLICATION FOR PERMIT D y*/ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT '*r <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA MAR 1 6 19$@ <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED ENVIROMENTAL HEALTH <br /> (Complete in Triplicate) FERMIT/SERVICES <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. <br /> Job Address L U City S40(khO Lot Size I J O i /�FC>` PM <br /> Owner's Name <br /> ,rr�,�rt'�s W 1 S�1/Address �� �✓1 S�. � �f'E' Phone <br /> -12 <br /> Con44 <br /> tractor —� .�. Address'-77 �"" r ' ' Li�e�i "Nb`� �' 7'�hone'_ ' <br /> TYPE OF WELL/PUMP: NEW WELL''- WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR'❑ OTTHIER ❑ <br /> " DIO' <br /> STANCE TNEAREST: SEPTIC TANR : &�'+f`x"'SEINEN LINr�S 11ISPOSAL M)7110-A PROP.-LINE <br /> &­-- <br /> FOUNDATION AGRICULTURE WELL• � OTHER,WELL- i PITS/SUMPS, <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION <br /> [IC1 �� , <br /> Industrial Open Bottom Manteca Dia. of Well Excavation I Dia. of Well Casin <br /> Domestic/Private 0 Gravel Pack ❑ Tra4y Type of°Casing-rW-- � r .._Ir Specifications i���jtlf <br /> [7 Public F1Other ❑ Delta i Depth of Grout Seal T pe of Grout _ <br /> I I Irrigation —.Approx. Depth , I I Eastern Surface Seal Installed by 57 in V_&— <br /> -Repair Work Done ❑ Type of Pump H.P. `•t I State Work Done <br /> Well Destruction ❑ Well Diameter , "' Sealing Material (top.0w a <br /> Depth �--� --_ 1 FilEer Material (B w 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATtON,I_1 REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system perrhitted if public sewer is i <br /> available within 200 feet.l <br /> Installation will serve: Residence— Commercial l Other+ --�- i <br /> Number of living units: Number of bedrooms <br /> N <br /> Character of soil to a depth of 3 feet: Water table` depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> u •' <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to.�er.,v. Well Foundation Property Line a 4•- <br /> t <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: W 1 oundation Property Line <br /> -- — <br /> SEEPAGE PITS I I Depth�,, - Siie— ,N_umh_er, •-•-— - .— ., <br /> SUMPS ❑ Distanc nearest: Well FoundationN Property Line <br /> DISPOSAL'PONDS ❑ 1kt <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 <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, 1 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 Californ' <br /> The applicant mu for all required in ectio Mete drawing on reverse side. <br /> Signed X Title: _ a Date: <br /> ` FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area 01 _ <br /> Pit or Grout Inspection 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 INFO �yAMOUNT DUE AMOUNT REMITTED CK 9 <br /> CASH RECEIVED 6Y DATE �PE(RRMIT'N+O. <br /> r EH 13-24IREV.i/n5) '"R O i{.� LA�V-�r �(X r 76EH�44-21tJ [}U /VV V <br />