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9 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Et- r <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> NO B rlL t <br /> (Complete in Triplicate) D <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 /> 4 <br /> Job Address 3 2 City Lot Size tosl� J PIV1 <br /> x Owner's Name Ma YG �r�ddress �C3� 's.• .--„_ Phone <br /> f <br /> I Contractor Address License No. Phone_ <br /> TYPE OF WELL/PUMP: NeW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS \V{ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 6 ' <br /> f'1 Public f i Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation —_Approx.,Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction , ❑ Well Diameter, Sealing Material (top 50') r I <br /> Depth Filler Material (Below 50') f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t-1 REPAIR/ADDITION l ) DESTRUCTION INo septic system permitted it public sewer is <br /> available within 200 feet.) (��` <br /> Installation will serve: Residence_ Commercial_ Other <br /> i r <br /> Number of living units: Number of bedrooms <br /> Character'of soil to a depth of 3 feet: I Water table depth <br /> SEPTIC TANK ❑ Type/Mfg i apacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ I Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> LEACHING LINE ❑ No. & Length of lines Total length/size , <br /> FILTER BED ❑ Distance to_nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth f Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ E <br /> I hereby certify that t 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 must call for all required inspections..Complete drawing on reverse side. �] <br /> Signed Title: Date: <br /> ]\ F DEPARTMENT USE ONLY <br /> Application Accepted by ] Date <br /> Area <br /> Pit,or Grout Inspection by Date Final Inspection by wDate 1 <br /> Additional Comments: � 1 3 � j� <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, Stk., CA 95201 <br /> d <br /> { <br /> FEECK 11 <br /> INFO MOUNT DUE AMOUNT REMIT-TED CASH RECEIVED BY DATE ,J PERMIT'NO. <br /> +.EH 13-241REV,1i951 316 <br /> EH 14-26 <br /> «:c <br />