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w APPLICATION FOR PERMIT <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I 1601 E. HAZELTON AVE., STOCKTON, CA <br /> j Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> i (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 �ad23I Se City of Size PM <br /> 1 s <br /> Owner's Name Address X11 Phone <br /> t� <br /> Contractor ctt_. ,__5�ddress a--��PLiXnse No. 4Z Phonei� —��L. <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 \iTELL OTHER WELL— "~ —PITS/SUMPS_-w.4.,:..�-. -- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Q <br /> Y-4)omestic/Private" ❑'Gravel Pack y ­❑ Tracy + Type of Casing Specifications <br /> F-1 Public ❑ Other -f'' R-Delta- -,—. Depth of Grout Seal Type of Grout ` <br /> I I Irrigation _..Approx.,Depth 13 Eastern Surface Seal Installed by Vv <br /> Repair Work Done X, Type of Pump _. - H.P. ,CIS-e, State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it 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 'r,` <br /> SEPTIC TANK ❑ Type/Mfg! Capacity No. Compartments'�: y <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest-. Well Foundation Property Line r �rll~C �ti llllL~;r,tii <br /> SEEPAGE PITS l I Depth j Size Number <br /> SUMPS -_ ❑„,Distance to ngaTst: Well -Foundation' Property Line <br /> DISPOSAL PONDS ❑ <br /> 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." <br /> The applicant m II for all required inspections:'Compi'M drawing Onverse side. � <br /> Signed X c .� Title: ._ 02—per Date: g5i" <br /> R DEPARTMENT USE ONLY r� <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental health Permit/Services 1601 E. Hazelton Ave., P.O- Box 2009, Silk., CA 95201 <br /> 1- <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> +.EH 13-24(REV.1i85Y 3S C k <br /> EH 144-2B � 1 ,J <br />