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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT /] A-61\.Cv <br /> 1601 E. HAZEILTON AVE., STOCKTON, CA I e <br /> Telephone (209) 466-6781 f <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Nk-W <br /> (Complete in Triplicate) f <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/pun}p d the Rules and Regulations of the San Joaquin <br /> Local Health District—, J s' P4 e .l <br /> Job Address 0 C <br /> �� ity Xllej Lot size &46C,!:P Pill!_ <br /> Owner's Name f.l Address ., S�S� L s�'F�+j ,�f!_.�+ Phone <br /> Contractor's Name /LPA / License No. f �� � Phone <br /> TYPE OF WELL/PUMP: NEW WELL p WELL REPLACEMENT ❑ DESTRUCTION ❑ i <br /> PUMP INSTALLATION E� SYSTEM REPAIR El OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK /Svc SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation U; Dia. of Well Casing <br /> n <br /> ,1k Domestic/Private JW Gravel Pack ❑ Tracy Type of Casingy, C Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ,SC) f Type of Grout <br /> ❑ Irrigation __..._...Approx. Depth /r❑ Eastern Surface Seal.lnstalled by lazl, f l <br /> Repair Work Done ❑ Type of Pump u0 H.P. '2 State Work Done <br /> Well Destruction ❑ Well Diameter _ Sealing Material (top 501 C �.,>r, <br /> Depth Ota Filler Material (Below 501 &1_1 a 1& � I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available 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 <br /> SEPTIC TANK ❑ Type/Mfg' Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ d 1� I Method of Disposal <br /> Distance to nearest:: Well Foundation I Property Line c+ <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ j <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 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.". t .� <br /> The applicant must call'-for a I required_inspections. Complete drawing on rev rse side. 1 <br /> Signed Title: Date: <br /> , v <br /> FOR DEPARTMENT USE ONLY <br /> Appfication Accepted by Date — Ar / <br /> Pit or Grout Inspection by Date 3 Final Inspection by leDate- 7 <br /> .AJditiionall Comments: <br /> X�Stk 466-6761 I❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 <br /> 'Ap��p icant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> 17 <br /> • + EH 1424MEV.10/83) o o�� &S (dip <br />