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6 " <br /> I � <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE I ON AVE., STOCKTON, CA <br /> r' Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 0", a.. - <br /> (Complete in Triplicate) , <br /> Application is hereby made to the San Joaquin Local Health District fora <br /> made in compliance with San Joaquin County Ordinance No.549 for permit to862fo construct and/or install the work herein described.This application is <br /> Local Health District. sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Jab Address <br /> city Lot Size PM <br /> Owner's Name�S {- C614 r-jtJ r l rAdd <br /> ` ress �`"1 IG <br /> `�'^��SF'U�i� Phone 44 <br /> Contractor Address <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER El <br /> LINES DISPOSAL FLD. ROP. LINE <br /> FOUNDATION AGRICULTURE WELL 0TH L PiTS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU SPECIFiCATIONSf <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ TracDia:of Well Casing + <br /> Type of Casing Specifications <br /> ❑ Public L Other Delta Depth of Grout Seal . <br /> El Irrigation ---ATYpe of Grout <br /> epth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ype of Pump H.P. <br /> State Work Done <br /> Well Destr ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material f8elow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> installation will serve: Residence— Commercial_ Other available within 200 feet.} <br /> Number of living units: Number of bedrooms j <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK XWater table depth <br /> Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Q ' <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size 4 <br /> FILTER BED ❑ Distance to nearest: Well FoundationSr <br /> Property Line <br /> SEEPAGE PITS ❑ Depth Size t Number { <br /> SUMPS ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS r-1Property Line <br /> d <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. i <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 licant must call for ail required inspections. Complet cawing on reverie side. , <br /> Signed Title: <br /> Date: A k t.1 <br /> ; <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ��. <br /> Area <br /> Pit or Grout Inspection Date Final:Inspection by Date <br /> Additional Comments: may` / ! <br /> ❑ Stk 466-6781 ❑ Lodi 3621 ❑ Manteca 823-71 ❑ Tracy <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO RECEIVED BY DATE PERMITL'NO. <br /> ULA <br /> +'EN 13.24'IREIl.:ls%A 51 �L[""��'d <br /> .. EH X14-28 .• t��� / //� <br /> ,z <br />