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k <br /> F APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6781 <br /> PERMIT EXPIRES I`YEAR FROM-DATE ISSUED t 4. <br /> 1Complete inTriplicate)`• <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 Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address [7� iGil ! W� " City Lot Size PM <br /> Owner's Name "`"""`c q ` cldress Phone 4, Y ZZ I <br /> Contractor�a –r4-99dkA-r-t Address o L erg-+-moi License No. '7�r <br /> Phone *g 7 <br /> �r <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION � SYSTEM REPAIR.❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL-FLD_. PROP. LINE <br /> FOUNDATION I 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 /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> p Type p":rd� _— H.P. ��-– State Work Done v` <br /> Repair Work Done ❑ T e of Pum 7 <br /> Well Destruction ❑ Well Diameter;I Sealing Material {top 501 6' <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 6 <br /> available within 200 feet.) 0 <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Numberofbedrooms <br /> Character of soil to a depth of 3 feet: i Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ . i Method of Disposal ' <br /> Distance to:nearest: Well Foundation Property Line <br /> I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth i.L Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ '1 <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, 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 performanceemploy of the work for which this permit is issued, I shall em y persons subject to workman's compensa- <br /> tion laws of California."` <br /> The applicant inu t all for alpequired inspections. Complete drawing on reverse side. <br /> 1 5 <br /> Signed Title; Date:S <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by - Dater Area ®� I <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 /> INFO FEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY c� DATE PERMIT"NO. <br /> + EH13-24(REV.t/9 5) .S <br /> EH 114-26 <br />