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�" APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON CA i <br /> Telephone (2091 466-67$1 a <br /> P <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,-:- <br /> 1 <br /> (Complete in Triplicate) T " n K s 4,, <br /> Application is hereby madetothe 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 th*Aµles andRegulatrons of the San Joaquin <br /> Local Health District.. <br /> Job Address29 City <br /> Owner's Name,, ress <br /> !� AddPhajle <br /> LicenPho <br /> Q 4� <br /> Contractor's Name -� se No. ne <br /> TYPE OF WELL/PUMP: NEW-WELL ❑ WELL REPLACEMENT ❑ I3ST,RUL"710N,-IJ <br /> Pl1MP,tNSTALLAT10N ElSYSTEM.REPAIR `'i r + �klleR <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOS4 F0. ­ <br /> PE P l INE <br /> FOUNDATION l AGRICULTURE WELL OTHER WELL_ PITSIP.W S ' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j r r <br /> D Industrial ❑ Open Bottom' ❑ Manteca Dia. of Well Excavation Y Dia• of Weir Casing' <br /> €'. <br /> 4. El Domestic/Private El Gravel Pack:.. ❑ Tracy Type of Casing Y b Spacrfiga $ris <br /> �. Public ❑ Other I] Delta Depth of Grout Seal Type of Craut lY <br /> ❑ Irrigation- ---Approx. Depth ❑ Eastern Surface Seal Installed by N n <br /> Repair Work Done Type of Pump 1 H.P. State Vy.4rk Dgne, <br /> Well Destruction ❑dr. Well-Diameter + Sealing Material ltop.50,1 <br /> r <br /> Filler Material iBelow-W-),v <br /> Depth - - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION E REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is <br /> ayallable'within 200 feet,r <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: Water tahied epth <br /> SEPTIC TANK ❑ Type/Mfg l Capacity---L_*1,�NoCompartments <br /> PKG. TREATMENT PLT. ❑ Method ofDisposal <br /> Distance to nearest: Well Foundation Property liria <br /> LEACHING LINE E3No. & Length of lines Total length/size ' <br /> FILTER BED El Distance to nearest: Well Foundation �_ Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance tonearest: Well Foundation Property.Line ;r <br /> DISPOSAL PONDS El <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sato 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,f¢r which this permitis issued, I shall not <br /> ensation laws of California."Contractor's hirin <br /> employ any person in succi manner as to become subject to workman's compg or sub contracting signature <br /> certifies the following:"I certify that in the iperformance of the work for which this permit is issued,I shall employ persons subject to•workman's compensa- <br /> tion laws of California." t _, <br /> The appli� call for all required ' pec' ns. C late drawing on revy9 side. <br /> Date:° <br /> Signed v Title: <br /> FOR DEPARTMENT USE ONLY <br /> Date Ar ` <br /> Application Accepted by ry ! a I_p7 <br /> f <br /> Pit or Grout Inspection by <br /> Date Final Inspection by ` " Date 7 U <br /> Additional Comments: <br /> ❑ Stk 466.6781 ❑ Lodi 369-3821 ❑ Manteca 823-7104 ❑ Tracy 635 <br /> i Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave P.O.kQoK 2008s A 5511' <br /> IFEE <br /> NFO AMOUNT DUET AMOUNT REMITTED CASH <br /> RECEIVED BY _DATE PERMIT'NO. <br /> +Eli1324 IREY.101831 <br /> EH 14.26 - r isNk 'c i <br />