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: t <br /> '- APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON 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 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 /> Job Address 4 City C4 Lot Size PM <br /> Owner's Namel_Jdl]UI 1&10e4t Address q-117) L�L6E QA10 _*VZq Phone W) <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSi <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` <br /> ❑ Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r, <br /> 71 Public ❑ Other y ❑ Delta } Depth.of Grout Seal Type of Grout <br /> I I Irrigation --Approx. Depth I-IEastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H,P. State Work Done— <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIR/ADDITION I 1 DESTRUCTION INo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> i <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 = f" -Capacity No. Compartments <br /> PKG..TREATMENT PLT. ❑ Method of Disposal <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 C I Depth = Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ; <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 rdgulations of the San Joaquin Local Health District. F <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 <br /> lffor <br /> �all required inspections. Complete drawing o reverse side. <br /> J <br /> Signe dj� / �� Title: �Z Bu14J�'� Date: la <br /> S 1 <br /> j� Ate! 4C V30JL Gut t <br /> c FOR DEPARTMENT USE ONLY 1 <br /> Application Accepted by Date - Area 1 v <br /> / Gr. <br /> Pit or Grout Inspection by Date Final Inspection by Data i <br /> Additional Comments: U <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 CI Tracy 835-G385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO AMOUNT DUE AMOUNT,REMiT•TED- CK97) RECEIVED BY,. DATE PERMI7'NO. <br /> EH13-24(REV.I x 51 �� �} <br /> EH 1426 f !I i f- <br />