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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL'HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone {209} 466-6781 <br /> PERMIT EXPIRES 1'YEAR'FROM-DATE ISSUED z' <br /> ICornplete in Triplicate}" <br /> Application isherebymade to the San Joaquin Local Health District fora permit toconstruct and/or install the�work'herein described. This application ii- <br /> made <br /> Lo al in o hpli stcetwith San Joaquin County ordinance No .549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> . _ 1 <br /> Job Address a S .. <br /> coh.f}✓✓ "� ( .. �i G City Lot Size PM <br /> CU <br /> 4fsame AL6 -Address 17-.50 1 Phone- <br /> Contractor 1 / AddressZ AZ License NoaR,79iw Q Phone U` <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [I DESTRUCTION ❑ <br /> PUMP_INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f <br /> INTENDED USE TYPE]OF WELL s,,PROBLEM AREA CONSTRUCTION SPECIFICATIONS j! ; <br /> ❑ Industrial <br /> ❑ Open Bottom Cl Manteca Dia, of Well Excavation Dia.of Well Casing i <br /> Domestic/Private ❑ Gravel Pack * ❑ Tracy Type of Casing Specifications 3 <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout )U 0 <br /> ❑ Irrigation _,__Approx. Depth E] Eastern Surface Seal Installed by �y <br /> Repair Work Done ;< Type of Pump C L� H.P. State Work Don <br /> ' Well Destruction O rWell Diameter Sealing Material (top 50') t <br /> k <br /> Depth . Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public'.-Sewer is <br /> T available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other J <br /> Number of living units: Number-of.,bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth f <br /> SEPTIC-TANK.--.,,- []---Type/hAf <br /> 9 Capacity - No. Compartments <br /> PKG. TREATMENT PLT. ❑ +I ' + <br /> r Method of Disposal <br /> f Distance to'nearest: Well, Foundation ' Property Line I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size 4- <br /> - <br /> e FILTER BED ❑ Distance to nearest: Well Foundation Property Line i '+ <br /> r` SEEPAGE PITS` O Depth t t Size ZJ <br /> SUMPS. Yt _ ❑' Distance to nearest: Well Foundation umbePro a Line <br /> _ ?.4.. _ 4�_-1 <br /> DISPOSAL PONDS ❑ p <br /> Il here6 certi <br /> y fy'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 /> y 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 /> tionda ks of Cam omla."_ ti ,{ <br /> The applicant s call for all it d <br /> pections. Complete drawing on r side. rn � <br /> Signed Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> a F <br /> Application Accepted by Date- `~CI `d <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> +•-,.k <br /> Additional Comments: + " �2� �>� <br /> ElStk 466r67$1 ❑ Lodi 369-3621Manteca 823-7104 ❑ Tracy 8355-638.5 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952Qll4,_„� <br /> FEE AMOUNT DUE ' AMOUNT REMITTED <br /> INFO Q CASH RECEIVED BY DATE PERMIT"NO. <br /> + EH13-24fREV-i/s el ` _, 5-R <br /> EH 14-26 ' d-76 <br />