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- _ APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT [ � <br /> 1601 E. HAZE T ON AVEs, 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 welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Cit u erg <br /> Job Addross S <br /> j�17 N P ���A? yr ��n•• Lot Size PM <br /> Owner's Nam <br /> rk W/ IV V 1 7 Phone <br />� �-- --Contractor Address <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 1-1WELL REPLACEMENT LD DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> 91E <br /> DISTANCE TO NEAREST: S91PTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ 'Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Type L1T Domestic/Private ❑IGravel Pack ❑ Tracy YP of Casing Specifications <br /> Type of Grout <br /> — <br /> Fl l Public (1;Other 11 Delta Depth of Grout Seal — <br /> I I Irrigation .-Approx. Depth l I Eastern Surface Seal Installed by — (A <br /> Repair Work Done ElType of Pump H.P. State Work Done <br /> _ Y. <br /> Well Destruction Well Diameter Sealing Material (top 501 <br /> I Depth Filler Material (Below 50') t. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR IADDITION t I DESTRUCTION (No septic system permitted if public sewer is <br /> IN available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: <br /> �M Number of bedrooms 1 <br /> Character of soil to a depth of 3 feet- Water table depA <br /> SEPTIC TANK ❑ Type/Mfg } Capacity No. Compartme <br /> PKG. TREATMENT PLT. ❑ Method of Disp <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 l I Depth Size Number — <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ' <br /> I hereby certify that I have p.spared this application and that the work will be done in adcordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the ban Joaquin Local Health District. <br /> ,r <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 runner 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 applicant must call for ah uired inspections. Complete drawing on reverse side. <br /> r r .^g7 <br /> {� Signed I�� Tiile: C N2r Date: " a <br /> 4 iJ� <br /> i R DEPA TMENT USE ONLY 2.0 <br /> Application Accepted by Date 191— <br /> Area <br /> Pit or Grout Inspection b II Date Final Inspection by Date j <br /> I � <br /> Additional Comments: a <br /> ❑ Stk 466-67!31 ❑ 6odi 369-3621 ❑ anteca 823-7104 ❑ Tracy 835- <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 CASH RECEIVED BY DATE PERMIT'NO. <br /> r <br /> + EH 13-24 MEV..,/H 51 INFO <br /> EH 14-26 y - <br />