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APPLICATION FOR PERMITji <br /> w <br /> w 1.r ra SAN JOAQUIN LOCAL.HEALTH DISTRICT <br /> 1601 E. FiAZELI ON AVE' STOCKTON, CA <br /> SAN JOA00IN LOCAL Telephone (209) 466-6781 IV " <br /> 14EALTH DISTRICT 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 /> D . 1)/..P$ o Size <br /> PM <br /> Job Address City _ v <br /> Q Phone <br /> Owner's Nam , <br /> r. r _ ` <br /> Contractor's Name f f t License No. Phone <br /> TYPE OF WELL/PUMP: NEW WEL1 ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 'SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINESDISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL 4~ _ OTHER WELL PITS/SUMPS <br /> TENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom ❑ Manteca Dia.-of Well Excavation Dia. of Well Casing N <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Typ`,of Casing Specifications <br /> ❑ blic ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> Irrigation _�lpprox. De�th ❑ Eastern Surf pe al Installed by <br /> Repair Work Done Type of Pump �►// H.P. State Work Doneor <br /> Well Destruction ❑ Well Diameter Sealing Material(top 501 'n <br /> Depth Filler Material-,(Billow 50') ') <br /> l TYPE OF SEPTIC WORK:` NEW INSTALLATION ❑ REPAIR/ADDITION..❑: DESTRUCTION ❑_SNo-septic system permitted if public sewer is <br /> k avail5bie within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms Q <br />' Character of soil to a depth of 3 feet: Water table depth - <br /> SEPTIC TANK ❑ Type/Mfg i Capacity No. Compartments <br /> l PKG. TREATMENT PLT. ❑ � i � Method of Disposal <br /> V <br /> Distance-to nearest:— -—Well- :=-' -"'-Foundation—�— --Property-Line_ <br />€ LEACHING LINE ❑ No. & Length of lines Total length/size <br /> k FILTER BED ❑ Distance to nearest: Well I Foundation� Property Line <br /> SEEPAGE PITS ❑ Depth Size I YNumber <br /> I. SUMPS ❑ Distance to nearest: Well Foundation t Property Line <br /> 1 c <br /> ­SUMPS <br /> PONDS ❑ <br /> ( 1 hereby certify that I have prepared this application and that the work will,be done in accordance with'Sari Joaquin county ordinances;state laws, and <br /> k rules and regulations of the San Joaquin Local Health-District. ;' I r <br /> Home owner or licensed agents signature c`ert'ifies thee-following: "I certify that in the performance of the work fo%which this permit is issued, I shall not <br /> employ any pe in ch manner as to become subject workman's compensation laws of California." Cantracfors-hiring or sub contracting;signature <br /> certifies the f awing: " certify that in theEper 'of a work-for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> • tion laws of alifornia." f f; <br /> f The applic nt m I r all r ued ' pi a drawing on reverse si <br /> ( Y ' <br /> Signed Title: �' Date: <br /> FOR DEPARTMENT USE ONLY � r � <br /> C� 3 <br /> t Application Accepted by Date- <br /> Pit or Grout Inspection by Da I "Final Inspection by 1 Dated Z - <br /> d A <br /> Additional Comments: y '� <br /> ❑ Stk 466-67$1 ❑ Lodi 369-3621 ❑ Manteca 823-7104 +❑ Tracy 835-6385 <br /> Return all copies to: Environmental Health Permi !Services}}601 E. Hazelton Ave.;`P.O. Box 2009, Stk., CA 95201 <br /> Applicant <br /> _ r �.�_,Q,�`rw. <br /> ` FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT''NO. <br /> k{ • INFO CASH <br /> + EH 1324(REV.10193) —IS O o t <br /> 1 EH 14-26 - _ <br />