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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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address PC�C dlu City <br /> IF <br /> N! _ tX'! ��QI A11419-CA-2 � � �°�dt Size PM <br /> Owner's Name �lQ lr�CLlti,&d) iAddres�,loval x ...J3 LL J[.0 fPhone <br /> _Z23_7111 <br /> Contractor Address icense No. Phone <br /> TYPE OF WELL/PUMP: it NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 06 tle, SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL --PITS/SUMPS, V <br /> INTENDED USE TYPE:OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation r. Dia. of Well Casing <br /> ❑ Domestic/Private �(Gravel Pack LJ Tracy Type of CasingUt". Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal /70176_ Type of Grout Z2611494r <br /> Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by , <br /> Repair Work Done Cl Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 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: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance 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 /> 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 /> 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 appli ant u call for all requ'red inspections. Complete drawing onreverse side. <br /> ' J <br /> Signed Title: Iy . C Gt�l+9,C�Cl� — Date: +� <br /> ENT USE ONLY <br /> Application Accepted by 0�1. Z._ �, Data ��I Area 3 <br /> Pit or Grout Inspection by Dat Final Inspection by --�� — Date <br /> M; -Additional Comments: l �� - ,P& <br /> ❑ Stk 466-6781 ❑ Lodi 3693621 ❑ 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 /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASHRECEIVED BY DATE PERMIT'NO. <br /> + EH 13-241REV.1/851 <br /> EH 14-28 �7, <br />