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t I <br /> ` APPLICATION FOR PERMIT <br /> SAN JOAQUIN-LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. _ 4k <br /> Job Address`1 �r�c ►y, //1 i 7 7 ^� City Lot Size PM <br /> Owner's Name i-�� Address <br /> - I ! e <br /> Contracts z Address G. F7 License No. �b�Z Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ _ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE i <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 /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal_- i= n Type of Grout O <br /> v <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. I State W&IJDbne <br /> Well Destruction ❑ Well Diameter Sealing Material (top 56) � <br /> Depth filler Material (Below 509' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR ADDITION DESTRUCTIDiV ❑ (No`sej3tic system permitted if public sewer is �J ' <br /> available within 2DD f et.) <br /> _ .-Installation will serve: Residence Commercial_ Other <br /> Number of living units- j Number_of_p Brooms <br /> q X O <br /> Character of soil to a depth bf 3 feet: �~ - %�- ` Water table depth <br /> SEPTIC TANK ❑ Type/Mfg I � Capacity . No. Compartments <br /> PKG. TREATMENT PLT. ❑ f v Method of Disposal <br /> bistance to nearest: Well Foundation Property Line " <br /> 4 <br /> LEACHING LINE 141" No. & Length`of lines 2 ­1 (/Qf - Total'length/size ' oy <br /> FILTER BED ❑ Distance to nearest: Well .5 Foundation �p rL Property Line. <br /> it <br /> SEEPAGE PITS bepth Sizet„7 fQ � Number <br /> SUMPS ( Distance to nearest: ' Well 106 Foundation cif) 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•hiting 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." I 1 F <br /> The applicant must call for all requir t inspections. Complete drawingowerse sidef. <br /> Signed X t Title: V: Date: - 0""', <br /> LES { <br /> FORD PARTMENT USE ONLY _ <br /> T:ej <br /> i <br /> Application Accepted by Date Area <br /> -yr /�/ <br /> or Grout Inspection by ate rte— Final Inspection by! / : /i�fZ� Date <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 D Tracy 835-6365 'q <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.Bax Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24(REV.I/A 51 __7 iki <br /> EH 1426 <br />