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r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQ.UIN'LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL-I 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.'1851 for well/pump and the Rules and Regulations of the San Joaquin 1 <br /> Local Health District. `� <br /> Job Address I! 0 r '" f�� Ci OC O Lot Size PM <br /> r r <br /> 09 V 1� f T r Address 'O'>�o A ` �fl �i4 Phone <br /> Owner's Name � - <br /> j8R N�I1J Phone <br /> ontrac r A'T� �. Address <br /> �TYPE OF WELL/PUMP: EW WELL REPLACEMENT ❑ DESTRUCTION ❑ , <br /> PUMP INSTALLATTIIOri SYSTEM REPAIR ❑ OTHER. ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _j SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom EJ Manteca Dia. of Well Excavation Dia. of Well Casing ' <br /> *%Domestic/Private *;K Gravel Pack ❑ Tracy Type of Casing Spec cations <br /> i <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal + Type of Grout <br /> ❑ Irrigation ---Approx. Dept El Eastern Surface Seal Installed by 1� 1 /-14 <br /> Repair Work Done [:1 Type of Pump 11� H.P. State Work Done / 37/O /, <br /> YO <br /> Well Destruction L) Well Diameter Sealing Material {top 50'1 .408 �� <br /> Depth Filler Material {Below 501 <br /> E OF SEPTIC WORK: NEW INSTALLATION E:1REPAIR/ADDITION LJ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) r <br /> f <br /> installation will <br /> Residence Commercial_ Other <br /> Number of livinNumber of bedrooms A Y+ <br /> Character of soepth of 3 fee . Watertable depth <br /> SEPTIC TANK ,,❑`._Type/Mfg Capacity No. Compartments i <br /> PKG. TREATMENT PLT:❑ } <br /> Method of Disposal <br /> 1. <br /> Distance to nearest: Well ndation Property Line <br /> i E <br /> LEACHING LINE `.❑ _No.::& Length of linea length/size a �, <br /> FILTER BED~ ❑ Distance to nearest: Well Foundation Pro Line=. <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ."❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS : ❑ i <br /> I hereby certify that"I heave prepared this application and that the work will be done in accordance with San Joaquin county"ordinances, state laws, and <br /> rules and regulatioris of the San Joaquin Local Health District: } 1: `...- <br /> 1 Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for.1hich this'permit is issued, I shall not <br /> l 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: ' m <br /> ,'I certify that in the performance of the work for which this perit is issued,I shall employ persons subject to workman's compensa- <br /> I tion laws of California." k r <br /> The applicant II f ired inspections. Complete drawing on rev rse side. <br /> Signed Title: yV �O T Adze Date: <br /> - FOR p PAR MENT USE ONLY �} <br /> G Application Accepted by <br /> Date , Area t/ <br /> Pit or Grout4lnspection'by ' Y F Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781;x"❑ Lodi 369-3621 ❑ Manteca. $23-7104 ❑ Tracy:-836M% <br /> Applicant-Return 11 <br /> Return to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUEAMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. <br /> INFO / <br /> i �`?-3 <br /> + EH 13-241REV,1/85l 1 V,--Z----1a1^�r <br /> EH 1426 1�✓ . <br />