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APPLICATION FOR PERMIT <br /> SAN JOAO,UIN'LOCAL HEALTH DISTRICT <br /> A-A\ 1601 E. HAZEILTON 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 appi'caa q is <br /> made in compliance with San Joaquin County Ordinance No.54.9 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District.` <br /> _ Lot Size PM <br /> Cit <br /> Job Address -21V642 y <br /> sJ � ddress - Phone <br /> Owner's Name ��- <br /> Address <br /> rise No_�7e Pfione <br /> - <br /> Contractor r <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> =PUMP INSTALLATION.❑ .M ^ ^SYSTEM REPAIR•❑ -- OTHER.❑:.,..ra Q' <br /> DISPOSAL FLD. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> PROP. LINE .. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial <br /> F] Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> T of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy, <br /> Type Typo of Grout <br /> ❑ Public i.Q'Other ❑ Delta Depth of Grout Seal <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H p State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth ,..'Filler Material (Below 501 <br /> r YPE OF SEPTIC WORK: NEW:'INSTALLATION ❑ REPAIR/ADDITION O DESTRUCTION (No <br /> septi s tem emitted it public sewer is <br /> ` Installation will serve: }Re Hence Commercial Other <br /> Number of living units: Number of bedrooms — <br /> Character of soil to a depth of 3,feet: � Water table depth <br /> A -Ca NCompartments <br /> f 4SEPTIC TANK d Type/Mfg pacity o. r <br /> PKG. TREATMENT PLT. ❑_ Method of Disposal ` <br /> I Distance to nearest: Well yF Foundation Property Line <br /> �77F5 Total length/size <br /> zLEACHING LINE �' ❑t �No.,& Length of lines � <br /> ,FILTER BED <br /> E17 to nearest: wellFoundationProperty Line <br /> r " �. !j A=CC <br /> ` t Number [ # <br /> SEEPAGE PITS f`❑_- Depth _,iU ^ - -Size a <br /> SUMPS El .Distance to nearest:Y Well �ry_ Foundation r� Property Line <br /> V <br /> k 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 became subject to warkman'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 in s Complete drawing on reverse side. <br /> t �I Title: +c Date: <br /> Signed;it_ <br /> n FO PARTMENT USE ONLY t <br /> Applicaflion Accep d by <br /> Date �' ` Area <br /> ate �.- Final Irispection Date �` <br /> Pit or Grout lnspe�ti y <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 [2 Manteca 623-7104 El Tracy 635-63M �-✓ <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE CK RECEIVED BY DATE PERMIT NO. , <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH -Y <br /> + EH 13-24(REV.1/8 5) p �{//T/97 <br /> EH 14-26 - _ <br />