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v, <br /> APPLICATION FOR PERMIT n <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT. V }}11 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DEC 2 41957 <br /> (Complete in Triplicate) ENVIROMOTAL HEALTH <br /> Application is hereby made to the San Joaquin Local Health District forinstall HERMIT/SERVICES <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and he Rules and R described. SI�Joaq n <br /> Local Health District."=./f; •w ,., b p p eg oaquin <br /> Job Address Q 6 61 1 � s <br /> 4—.I l+ _ City Lot Size <br /> �_ - 1 PM <br /> Owner's Name �Ve. ¢r'l d f Address _ �j.y-R�f f��c� �r,� <br /> rf Phone <br /> Contractor / Address +� A <br /> TYPE OF WELL/PUMP: NEW WELL ,1( icerise Na.��Phone Z� <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST. SEPTIC TANK OTHER ❑ i <br /> -7 _ SEWER LINES <br /> FOUNDATION DISPOSAL FLD: PROP. LINE � <br /> AGRICULTURE WELL T t1 <br /> OTHER WELL PITS/SUMPS <br /> INTENDED USE ;TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI S f� <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavati <br /> XDomestic/Private Dia. of Well Casingn <br /> Gravel Pack Pi xacy Type of Casing l <br /> AL— <br /> ID Public ❑ 0 er ❑ Delta Specifications p <br /> El Irrigation Depth of Graut Seal Type of Grout <br /> —&Depth ❑ Eastern Surface Seal Installed by vP <br /> Repair Work Done ❑ Type of Pump H.P. r' <br /> Well Destruction ❑ Well Diameter. Sealing Material {top State Work Done V� <br /> 50'1 ` <br /> Depth <br /> Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is V <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 depth of 3 feet:ei E <br /> SEPTIC TANK ❑ Type/Mfg Water table depth j <br /> PKG. TREATMENT PLT. Eli! Capacity No. Compartments <br /> t <br /> I Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED <br /> ❑ Distance to}nearest: Well Foundation <br /> I Property Line <br /> SEEPAGE PITS ❑ Depth s Size <br /> SUMPSNumber <br /> ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property_Line <br /> 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 <br /> employ an that in the performance of the work for which this permit is issued, I shall not <br /> P Y y 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." <br /> The applicant all for al requir in ctians. Complete drawing on r verse side. <br /> Signed � � <br /> Title: Date: 4 <br /> f FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date <br /> G .Area <br /> Pit or Grout Inspection by Date �'�o <br /> tt Final Inspection by Date <br /> Additional Comments: f t <br /> ❑ Stk 466-6781 ' ❑ Lodi 369-3621 El Manteca 823-7104 ❑ Tracy 83546385 <br /> Applicant- Return ail copies to: Environmental Health Permit/Servioes 1601 E. Hazelton Ave., P.O. Box 2009 Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY PATE PERMIT'NO. <br /> + EH 13-24(REV.1/8 5) 7�:� i �G-A_^�EH 10.29 l —ar VU <br /> , <br />