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— _ APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT s <br /> 1601 E. HAZELTON 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.509 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> n A' <br /> Job Address oC � !.�/�/ ;999? —1 E�/��s�i�.r Lot Size PM <br /> r Owner's Name L-��^''V%� Address /f�''�' QL/ Phone <br /> Contractor k4eeSnf4le Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> ` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _ <br /> DISTANCE TO NEAC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i. INTENDED USE TYPE OF WELL PROBLEM ONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open.Bottom ❑ Manteca Dia. o eye on Dia. of Well Casing _ <br /> ❑ Domestic/Private El Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> ix. ❑ Public ❑ Other ❑ Delta Depth of Grout Seal a of Grout <br /> ❑ Irrigation _,Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done (}e <br /> Well Destruction ❑ Well Diameter _ Sealing.Material (top 50') , r1i <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INS ALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (Nm septic system permitted if public sewer is 5,1 <br /> available within 200 feet.) <br /> Installation will serve: ResidenceCommercial_ that )� <br /> Number of living units: ��jj <br /> �—Z Num r of bedroopic± <br /> Character of soil to a depth of 3 feet: __��„�/ Vyater table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacny-a&ed"do. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: iWell Foundation Property Line <br /> LEACHING LINE P-*'No. & Length of linesTotal length/size <br /> nerC <br /> FILTER BED ❑ Distance to merest: ell ` Foundations` Property Line <br /> SEEPAGE PITS e-cepth Size Number A + <br /> SUMPS ❑ Distance to nearest: Well 44,Foundation /®p lC'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, an <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, 1 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 Kermit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicel wre " pectigns. Complete drawing on reverse aside. <br /> Signed X� s �.fV rd/ Title: �f Gam- Date: I �+ <br /> _ FOR DEPARTMENT USE ONLY <br /> Application Accepted by vf t•�(SL Date `A—t-9 --2y) Area <br /> Pit or Grout Inspection by pp �/ ate at Inspections <br /> n2f-7—tA <br /> Additional Comments: G Y ©� <br /> ❑ Stk 466-6781 ❑ I 7104 ❑ Tracy 835-6.385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> NFOFEE AMOUNT DUE MOUNT REMITTED K RECEIVED BY DATE PERMIT NO. <br /> �za � <br />