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J N <br /> f iJ i <br /> APPLICATION FOR PERMIT R' = y <br /> r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. hiAZELiON AVE., STOCKTON, CA AUG <br /> Telephone (209) 466-6781 SA IV <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED /-1 AJ0AQUIiV � r <br /> {Complete in Triplicate} plg7RIC - <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. <br /> Job Address e -u U City Lot Size PM <br /> Owner's Name Address _ ( �7 L . 1t1 I�CI �J IAl/jt / Phone + qq <br /> % <br /> Contractor's Name • License No. Phone + <br /> TYPE OF WELL/PUMP; V NEW WELL $-- WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST; SEPTIC TANK 6� SEWER LINES - DISPOSAL FLD. 6129- PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS tf <br /> ❑ Industrial ❑ Open Bottom 9�.11+F�nteca Dia. of Well Excavation Dia. of Well Casing <br /> Pvcmestic/Private M.Qr vel Pack ❑ Tracy Type of Casing i0V(?.J Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type Grout <br /> ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type_of Pump H.P. State Work Done <br /> Well Destruction Cl Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) O <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: .Number of bedrooms R <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 Q <br /> Distance to nearest: Well_ Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑. Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <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 /> 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 Cal'ornia." <br /> The appli an ust call for all r uir nspections. Com lete drawl on rse i <br /> Signed Title: Date: / 7 <br /> f R <br /> DEPARTNIWIT USE ONLY f p <br /> Application Accepted by ��� IL Date r b Area v <br /> Pit or Grout Ins ction b ��" "ate LJO Z Final Insp ction by D to� <br /> Additional Comments: -PJ U <br /> ❑ Stk 466-6781 ❑ LAdi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 f <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520. ff <br /> FEE AMOUNT DUE AMOUNTREMITTED RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> +EH1324IREV. 141831 3, d J �l 3 C9,� i�-bS�7 �.'7�" Y" h <br /> EH 1426 '7 <br />