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f <br /> r <br /> APPLICATION FOR PERMIT <br /> SAN JOAOUIN:LOCAL HEALTH DISTRICT <br /> j 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 /> Triplicate} <br /> , ; v�: , 1�.irT r <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.foT well/pump and the Rules and Regulons of the San Joaquin <br /> Local Health District. '" J_. , 4 s_ ,1 M . �.- V. me <br /> w .. <br /> Job Address ! 6 � City4AALot Size ' PM <br /> 5?ephAn 0• C&I 1up : " <br /> Owner's Name Address f�•d s Phone �� <br /> Contractor tT�WIFf-C'IvLr!-� ; Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION f } <br /> PUMP INSTA'L'LATION ❑ SYSTEM REPAIR ❑ OTHER ❑ /v r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 2©© DISPOSAL FLD. PROP. LINE <br /> r -- FOUNDATION —­­AGRICULTUREWELL-- 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 /> i <br /> ❑ Domestic/Private ❑ Gravel Pack. ❑ Tracy Type of Casing Specifications i <br /> ❑ Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout - <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> WeN-pe-sit=uction "�HCl rt Well Diameter> Sealing Material [top 501 <br /> Depth Filler Material (Below 501 ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑. REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is <br /> available within 200 feet.] 1` .E <br /> Installation will serve: Residence Commercial_ Other w <br /> Number of living units: Number of bedrooms i <br /> f Character of soil to--a depth of 3 feet: Water table depth <br /> SEPTIC TANK' �� ❑—Type/Mfg Capacity '-No Compartments 1 <br /> I PKG. TREATMENT PLT. ❑' Method of Disposal <br /> - Distance to nearest: Well foundation PropertyLine <br /> LEACHING.LINE.` ._ ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest:- Well Foundation Property Line <br /> I <br /> SEEPAGE PITS ❑ Depth ? Size Number <br /> SUMPS _ ❑*-Distance-fo nearest: =P Well -' Foundation — .Property Line- <br /> 'DISPOSAL <br /> - <br /> DISPOSAL PONDS ❑ <br /> ---1 herehy 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 /> tion laws of California." Mi <br /> The applicant m t c for all requir d i ctions. Complete drawing on reverse side. <br /> Signed X Title: :Date: <br /> FOR DEPARTMENT USE ONLY <br /> Applicationn Accepted by Date <br /> AreO <br /> Pit or Grout Inspection by Date Final Inspection by ='`� Date <br /> II- Additional Comments: T <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 AMOUNT DUE, AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> F + EH 13-24 IR t/H57 4 ` 1yfj 04 <br /> EH 14-28 1 <br />