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. ,PP. S LICATt !IONt 7 S.t tl'S '� ...f 1•! ,. �rrY' v 1 r� <br /> A .FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT d <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 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. 1 <br /> Job Address ._. s� 10 �-}w� �� Fhev-6 5-P, ON Lot Size PM <br /> ud Qk <br /> Owner's Name _ Address Phone <br /> Contractor L i`� Addressi i +i <br /> I2r_�r License fVorr�7J -Phone — p. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ;;p <br /> PUMP INSTALLATION ❑ 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 /> ❑ Industria! ❑ Open Bottom ❑ Manteca Dia. of 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 <br /> ❑ Irrigation ----Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> i <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> r` �� <br /> Depth Filler Material (Below 50'1 LY <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION V REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewef;0 <br /> available within 200 feet.) b <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: A_— Number of bedrooms� � a <br /> Character of soil to a depth of 3 feet: Water table depth jf <br /> SEPTIC TANK ❑ Type/Mfg L .� r%�.r1;% �� apacity - _]Cl No. Compartments <br /> PKG. TREATMENT PLT. ❑ / Method of Disposal L <br /> Distance to nearest: Well Foundation Property Line , <br /> LEACHING LINE ❑ No. 5-i, Length of lines `" y .-Total length/size Rntl <br /> FILTER BED CI Distance. <br /> 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 he 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 California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X_ a%[f _ Title: —A9 a ,Yf' _ Date: l <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by dlAA^--f Date '` Area L <br /> Pit or Grout Inspection by Date Final Inspection by 2) 'a <br /> Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 8355-6385 <br /> Applicant- Return all copies to: Environmental Heal h Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DILE AMOUNT REMITTED CASH RECEIVED BY r r DATE PERMIT NO. <br /> + EH1 -24{REV.iiH57 7a �d SO��S� �b41 �� <br /> EH 144-28 / W <br />