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APPLICATION FOR PERMIT <br /> - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 , <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IComplete 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. 1$62 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address �+ T {,i6t_je City 1 Lot Size PM <br /> Own1 <br /> er's Name J "� ���t?Z Address 4 Q Q. Phone <br /> Contractor Address J l/ 696—tucense No. l Phone 6yls -W <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ �V OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC-TANK �DZ� -SEWER LINES - '-DISPOSAL FLD.LS PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t� <br /> !I <br /> ❑ Industrial ❑ Open Bottom 17 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> �(Domestic/Private `Gravel Pack `Tracy Type of Casing 1✓ Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal _�f ��-5� Type of ut <br /> ❑ Irrigation ---Approxi Depth ❑ Eastern Surface Seal Installed by II <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 501 j <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> —. 1 available within 200 feet.) <br /> Installation will serve:Res-tdenC Commercial_ Other '^ <br /> Number of living units: Numbe drooms .-- S: <br /> Character of soil to a depth of 3 feet: Water table depth ij f <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments U 1 <br /> PKG. TREATMENT-PLT. ❑ 1 '~ Method of Disposal <br /> Distance to nearest: WellFoundation eQp rty Line <br /> LEACHING LINE ❑ NNo� go.�& h of lines Total length/size _ 11 <br /> FILTER BED ❑�-Distance to nearest: Well Foundation Property Line I? <br /> -SEEPAGE'PITS ❑ Depth + J — Size Number <br /> � <br /> j <br /> SUMPS ❑ Distance to nearest: 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. I� <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 followin': "I certify that in the performance of the work for which this permit is issued,I shall employ *—",rte <br /> g fy pe p p y persons suhtect;toworkman's-Zompensa- <br /> tion laws of Cal'ornia." " <br /> The applic st call for all rqquirpf.inspections. Complete drawing on re rse side. <br /> 1•-s ,r- I <br /> �� _ <br /> Signed � Title: Date:• •'{c� <br /> IOR AR ENT USE ONLY <br /> Applicatia ccepted by Date 9� _R L <br /> Pit or rout spection at Final Inspection by _ __ Date ' <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M I <br /> Applicant- Return all copies to: EnviroAmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> H <br /> IEEE AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERNIM N0. <br /> AP <br /> + EH 13-24(REV.1/85) r � �T�_ 1�q— <br />` EH <br />