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-" APPLICATION FOR PERMIT <br /> { SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEI-TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 Y ' <br /> i PERMIT EXPIRES 1 YEAR:FROM DATE ISSUED - <br /> z (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 /> =r 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. ul <br /> K <br /> ♦'1'. <br /> Job Address k �6 City A Lot Size PM <br /> Owner's Name �� � �� � � a one <br /> Contractor Address License No.'k �Phone i <br /> TYPE OF WELL/PUMP: i NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION )0 R,C�0AWg*ZMTEM REPAIR ❑ OTHER ❑27 <br /> T <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE .r <br /> FOUNDATION AGRICULTURE WELL 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 /> O Domestic/Private ❑ Graveli Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other i ❑ Delta Depth of Grout Seal Type of Grout 4e <br /> ❑ Irrigation --Approx. Depth ❑ Eastern 5,yrface Seal Installed by <br /> Repair Work Done ❑ Type of Plump._. H.P. State Work Done r <br /> P <br /> Well Destruction ❑ Well Diameter{ Sealing Material (top 501 L <br /> Depth i ' Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is p <br /> e available within 206 feet.) <br /> Installation will serve: Residence'....—. Commercial Other <br /> Number of living units: - Number of bedrooms <br /> Character of soil to a depth of 3 feet: t Water table depth <br /> SEPTIC TANK El Type/Mfg i Capacity No. Compartments 1 <br /> PKG. TREATMENT;PLT. FI Method of Disposal <br /> { <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Ell-j No. &�Lerigth of lines Total length/size <br /> FILTER BED 1 Distance to nearest: 1T,Weli Foundation Property Line <br /> j r <br /> SEEPAGE PITS Qf DepthF Size Number <br /> SUMPS 1 [I Distance to nearest: Well Foundation Property Line `- <br /> DISPOSAL PONDS <br /> 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. e <br /> Home owner or licensed agent's signature certifies the following:"I,certify that in the performance of the work4or which this permit is issued, I shall not <br /> employ any person in such manner as to become subject�"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 fdr which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." A :Y <br /> The applicant a l Uv a require spa tions-Complete drawling on rse de. , <br /> Signed - Title: _ Date: <br /> ��Dat- <br /> R:VEPARTMENT USE ONLYApplication Accepted by ® 1�" Date �~ Area <br /> Pit or GroutInspecton 4 { Final Inspection by Dat <br /> Additional Comments: <br /> ❑ Stk 486.6781 ❑ 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 /> _ . _ . .- a_._._,r_ . -+-- <br /> —CK-#- <br /> -FEE' <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH f`RECEIVED BY - DATE PERMIT NO. <br /> + Eli 13.24 iREV.1/e 51 ,x _ <br /> 'EH W28 k' <br /> I <br />