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1�- <br /> .- APPLICATION FOR PERMIT r } <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA iskp W0VAA&A <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED �"'� $•L <br /> (Complete in Triplicate) k <br /> /or install the work <br /> n described. This <br /> cation is <br /> made ntcompliance with SanoJoaqu nthe SanCounJoanty Ordinance No. 549 for sewage or uin Local Health District fo.r a I permit <br /> 1862 for cwell/pump and the Rules and IR Regulations of the San l Joaquin <br /> Local Health District. ; <br /> T t <br /> Job City Lot Size PM <br /> Address `e Q <br /> Owner's Name <br /> Address <br /> Phone <br /> T r �- ress <br /> SO /� 3a t2 PhoneContractor License No. <br /> } TYPE OF\ ELLIIFU-MP: EW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE <br /> C FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> �❑ ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Indusfrial ❑'Open Bottom <br /> ❑ Do'm6stic/Private ' ❑ Gravel Pack ❑ Tracy Type of Casing <br /> Specifications <br /> Ll Other ❑ Delta Depth of Grout Seal Type of Grout <br /> �" .y „f'1 Public �. _ _ <br /> k A rax. Depth I I Eastern Surface Seal Installed by <br /> I I Irrigation. pP <br /> Repair Work Done ❑ Type of PI mp H,P. State Work Done well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth i Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1'i REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence) Commercial— Other <br /> 1' <br /> Number of living units: Number of bedrooms <br /> Character'of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK, ❑ Type_/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ — ' -' Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> " <br /> r Total len thlsize <br /> LEACHING LINE ❑ No. &+Length of lines w g <br /> t FILTER BED ❑—Dista to nearest: Well Foundation Property Line <br /> 1' e Number <br /> SEEPAGE PITS { I DepthA Size <br /> r <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 /> J "I certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: <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." # - <br /> The applicant must call for all required inspections. Complete drawing on reverse side. Ax-oh <br /> i Signed X Title: <br /> Date: <br /> p7{RZhRfNT-USE ONLY I <br /> 1 l <br /> Application Accepted by Date `-' Area L� — <br /> a <br /> Pit or Grout Inspecti y Data Final Inspection by Date <br /> Additional Commef+t5! <br /> ❑ Stk 466-6781 ❑ Lo 369-3621 ❑ Manteca a23-7104 ■ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 6Y DATE4995U201 <br /> PERMITNo. <br /> INFO <br /> r.EH 13.24(REV.)/H51 �V �V C � '-"_`� <br /> EK 14-26 - <br />