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I� <br /> APPLICATION FOR PERMIT r <br /> SAN!JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA ; <br /> i "Telephone (209) 466-6781 <br /> c - <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 /> �l' <br /> {k JI <br /> Cit <br /> Job Address d `y�lJL i`' r .S � %7 <br /> . y Lot Size PM <br /> Owner's Name Address _ k i�S' ]�Gl�/1J�1� Phone/ 4 F/ <br /> �l <br /> Contractor Address License No,�09Z Phone <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATfON ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION GRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C TION SPECIFICATIONS <br /> ❑ Industrial 11 Open Bottom ❑ Manteca Dia. of Well Excava Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ /Delta Depth of Grout Seal Specifications <br /> ❑ irrigation �4pprox. Depth ❑ ',Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Wel! Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth r Filler.Material (Below 50') ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑f REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> I ailable 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 Cl <br /> SEPTIC TANK ❑ Type/Mfg Capacity" - No. Compartments <br /> PKG. TREATMENT PLT. ❑ i <br /> Method of Disposal <br /> Distance to nearest: Well Foundation IProperty Line I 1 <br /> LEACHING LINE ❑ . No. & Length of lines Total length/size <br /> FILTER .BED ID Distance to nearest WeII Foundation Property Line <br /> _ I <br /> SEEPAGE PITS 171Depth Size Number i <br /> SUMPS ❑ Distance to nearest: Well •—foundation•• .- rt." Property Line <br /> DISPOSAL PONDS F] I1` <br /> I hereby certify that I have prepared this application and that the work will be dome 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."Contractors 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 inspections Complete drawing on reverse side. <br /> Signed X 614 r=2 a 42 Title: Date: <br /> FOR DE TMENT USE ONLY <br /> QL11 <br /> Application Accepted by `` Date Area <br /> Pit or Gout Inspection by Ir Date Final Inspection b i Dat <br /> i <br /> Additional Comments:� 4 <br /> �a l ci F <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 0 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CAS RECEIVED BY DATE= PERMIT N0. <br /> FM 3-24+ EH 14-28/REV.r i w sl ��U✓- ���C3[J. + jC?d -4� i <br /> f .II <br />