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i' <br /> APPLICATION FOR PERMIT <br /> F SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 �k h rein describ. TNs application is <br /> made in compliance with San oaquin County Ordin nc No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of th San Joaquin <br /> Local Health District..•N��e,=. <br /> I 49< <br /> Job Address Lef AB 796) ^ City Loi Size _ <br /> Owner's Name t�a Address _P V• '+� 4� 7 �3 [ , <br /> Phone <br /> Contractor's Name. _ hIQ <br /> License No. <br /> Phone kL <br /> `��•7 i <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT,❑ DESTRUCTION ❑ J <br /> PUMP INSTALLATION ' SYSTEM REPAIR'❑� OTHER❑ . <br /> DISTANCE TO NEAREST: SEPTIC TAMC /h 0 SEWER LINES DISPOSAL FLD. �-, <br /> °`i � PROP. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE.OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAtIONS <br /> ❑ Industrial g0pen Bottom ❑ Manteca Dia. of Well Excavation44 r f <br /> Dia. of Wel! Casing <br /> XDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing r .Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal T <br /> El Irrigation I r ype of rou; K <br /> p` App ox. Dedpth � �❑ Eastern Surface Seal Installed by <br /> Reparc Work Done ❑ Type of Pump'-_�_ H.P. State Work Done S <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50')tr <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ y REPAIR/ADDITION ❑ DESTRUCTION.❑ (No septic system permitted if public sewer is— <br /> available within 200 feet.I � <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 T <br /> _.— Capacity r•'- No. Compartments <br /> PKG. TREATMENT PLT:❑ ti .� <br /> Method of Disposal <br /> AT Distance to nearest: Well Foundation � �#operty Line <br /> k � ,i <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line 3 <br /> 'SEEPAGE PITS O Depth Size % Number <br /> SUMPS ❑ Distance to{nearest: Well Foundation '' •"""Property Line J <br /> 1 DISPOSAL PONDS 11 + <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 J <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 4 <br /> I 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 II for all requ'red ingpectio`s. Complete drawing on reverse side. <br /> I <br /> Signed Title: Date: <br /> # {{ <br /> FOR DE RTMENT USE ONLY d <br /> �8 <br /> 1 Application Accepted by Date Area <br /> rp d: <br /> Pit or Grout Inspection by Date Final Inspection � Date <br /> l Additional Comments: a �/ <br /> Ll 5tk 46fr6781 A ❑ Lodi 369-3621. ❑. Manteca 823-71 D4 L1Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health-Perrnif%Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> .._ ; <br /> FEE AMOUNT DUE''" AMOUNIT REMITTED YCK RECEIVED 8Y <br /> INFO CASH DATE f ERMIT N0.3-24 r <br /> r •"! 1 <br /> EH 14.281REV.101831 or 67 W 3�� �u- 176 w <br />