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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6781 <br /> !PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> �:.. (Complete in Triplicate) <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. v <br /> / C PM <br /> Job Address ff City S� Lot Size ; <br /> Addre P62 Rhon <br /> Owner's Name�^�;f.�Z4��1� "`�`�� <br /> r� Contractor AddressZVFI License No. Phon <br /> I <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ 4 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST,:.SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �— <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE ..TYPE OF WELL PROBLEM AREA . CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial t , ❑ Open Bottom ❑ Manteca �Dia.df 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 i <br /> Q Irrigation _ ' Approx. Depth -•ElEastern Surface Seal Installed by <br /> " State Work Done i <br /> Repair Work Done ❑ Type of Pump, H:P. - `°"' - � <br /> Well Destruction ❑ Well Diameter++l Sealing Material {top 501 <br /> ' Depth E Filler Material (Below 501 i <br /> DESTRUCTION El septic system permitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION <br /> t <br /> t available within 200 feet.) j <br /> Installation will serve: Res ence� Commercial Other y <br /> Number of living unitsZ- : Number of bedrooms N i <br /> Character of soil to a depth of 3 feet: Water table depth r <br /> SEPTIC TANK�fST❑ Type/Mfg apacity No. Compartments <br /> j ' Method of Disposal <br /> PKG. TREATMENT PLT. ❑ �� , I <br /> Distance to nearest: Well_ Foundation .- Property Line. <br /> LEACHING LINE No. & Length'of lines Total length/size X Z� l <br /> FILTER bED t ❑ Distance fto nearest: Well Foundation Property Line <br /> SEEPAGE PITS . Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS. a ❑ . <br /> I hereby certify that 1.have prepared thli 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 Heaith District. <br /> Home owner or licensed agents signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person ined a manner n to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:"1 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 must call or all required=pecti s. Complete retying on reverse side. — ✓�� <br /> w Rle; ► Date: <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> s Application Accepted;by Date ti a Area <br /> k. Pit or Grout Inspection by ' Date Final Inspection by Date <br /> .3 (0B�' <br /> Additional Comments: 7# <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca am-7104 U ❑ Tracy 635MM <br /> f Applicant- Return all copies to: Enviro <br /> nmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> E CK RECEIVED BY DATE PERMIT`NO. <br /> FEE AMOUNT DUE� AMOUNT REMITTED CASH <br /> INFO <br /> C <br /> , <br /> +EH 13-24)REV.1/e 5) vG <br /> EN 14-26 _ - - <br />