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_ r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELLTON AVE., STOCKTON, CA 1 <br /> Telephone (209) 466-6781 I <br /> •«.`PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) j <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 /> j <br /> Sarr'JoSq, .. , my%Ordrnahce No 549_forsewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in tompliar de with i <br /> Local Health.D�strrct` <br /> > <br /> Lot Size `` <br /> City t �/Lt2 PM I 1 <br /> Job Address <br /> E �, '�S Address C 17 G, ,� �l us- 'd 7 Phone <br /> Owner's Name <br /> 16 <br /> Contractor ��-5� � ""✓ Address aS 1L f`t L-if e n s e No. Q r Phone <br /> TYPE OF WELL/PUMP: NEW WELL C1WELL REPLACEMENT DESTRUCTION <br /> OTHER <br /> PUMP INSTALLATION 17 SYSTEM REPAIR El 196 El <br /> TO NEAREST: SEPTIC TANK �1n' - SEWER LINES DISPOSAL FLD. _� PROP- LINE <br /> FOUNDATION., ,AGRICULTIffiE WELL OTHER_WELL <br /> 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION <br /> Ll Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private Gravel Pack Tracy Type of Casing Specifications a <br /> [1 Public C1 Ot Ll Delta Depth of Grout Seal -� Typf of Grout L�f -. <br /> p� I .! <br /> 1 1 Irrigation �4 0 pprox: Depth I I Eastern Surface Seal Installed by - <br /> r H p State Work {Done <br /> Repair Work Done ❑ Type of Pump �— <br /> �v Sealing Material Ito 50'1 <br /> Well Destruction � Well Diamet�,r 9 p <br /> Depth 10471 Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION [ ]-(No ave septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial__ Other I' <br /> r' Number of.living units: Number of bedrooms <br /> { Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG.:TREATMENT PLT- ElMethod of Disposal r <br /> Distance to nearest: Well Foundation Property Line <br /> y <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> = Property Line <br /> � FILTER BED ❑ Distance to nearest: Well Foundation p Y l <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line r - <br /> DISPOSAL PONDS <br /> 1 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 /> ttt 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." <br /> I The applicant_lust call for all require inspections. C mplate drawing on reverse side -2 <br /> Signed X r 1 Title �-� Date: O <br /> L <br /> ` DEP TMENT USE ONLY <br /> I -fd <br /> Application Accepted by <br /> * iI hate r Area <br /> Pit or G out spectian by <br /> Date d Final Inspecti n by c Oat <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823- 04 ❑ Tracy 835-6335 <br /> 10 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 <br /> F AMOUNT DUE MOUNT REMITTED CK RECEIVED BYjATE. PERMIT'NO. �I <br /> INFO <br /> +.EH 13-24(REV.1./a 5) <br /> EH 14-26 <br /> Sly <br />