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t4 <br />APPLICATION FOR PERMIT 0 <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON AVE., STOCKTON, CA <br />Telephone () 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br />Local Health District. <br />Job Address ✓.e +�c r P��^`9l' ( City `® Lot Size 2- �* c ►' of PM <br />Q` % <br />Owner's Name •'[ �Ct 1 Qw�4�l Address <br />�- <br />Contractor V V <br />t Address <br />License No. o`iS Phone`'�b <br />TYPE OF WELL/PUMP: <br />NEW WELL Df WELL REPLACEMENT ❑ <br />DESTRUCTION ❑ <br />PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br />OTHER ❑ <br />DISTANCE TO NE)WET: SEPTIC TANK SEWER LINES DISPOSAL <br />FLD. PROP. LINE <br />- <br />FOUNDATION AGRICULTURE WELL OTHER <br />WELL PITS/SUMPS _ <br />INTENDED USE <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION 1/13 <br />❑ Industrial <br />❑ Open Bottom ❑ Manteca Dia. of Well Excava io <br />7` Dia. of Well Casing <br />❑ Domestic/ Private <br />A Gravel Pack ❑ Tracy Type of Casing <br />C Specifications <br />❑ Public <br />Irri <br />❑ Other ❑ Delta Depth of Grout Seal O T of Grout <br />ti00�py�� <br />---Approx. Depth ❑ Eastern Surface Seal Installed <br />by M4 vI'"r► <br />Repair ork'Done✓ ❑ <br />Type of PumpH.P. <br />State Work Done <br />Well Destruction ❑ <br />Well Diameter Sealing Material Itop 501 <br />Depth Filler Material (Below 501 <br />YPE OF SEPTIC WORK: <br />NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br />available within 200 feet.) <br />Installation rve: <br />Residence _ Commercial — Other <br />Number of living units: <br />Number of bedrooms <br />Character of soil to a depth of 3 <br />Water table depth <br />SEPTIC TANK <br />❑ Type/Mfg Capacity <br />No. Compartments <br />PKG. TREATMENT PLT. <br />❑ <br />Method of Disposal <br />Distance to nearest: Well oundation <br />Property Line <br />LEACHING LINE <br />❑ No. & Length of lines <br />1 length/size <br />FILTER BED <br />❑ Distance to nearest: Well Foundation <br />r Line <br />SEEPAGE PITS <br />❑ Depth Size Number <br />SUMPS <br />❑ Distance to nearest: Well Foundation _ <br />,— <br />PropertyLine <br />DISPOSAL PONDS <br />❑ <br />1 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, 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 permit is issued, I shall employ persons subject -to workman's compensa- <br />tion laws of California." <br />The applican ust call r all r quired inspections. Complete drawing on reverse side. <br />F. <br />Signed Title: Jsba+-r,1tL �T' Date: '?/1 <br />F R DEPAR NT USE ONLY <br />Application Accepted by Date An <br />Pit or Grout Inspection by Date Final Inspection by <br />Additional Comments:-� 6r/liG� <br />❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Man 823 04 ❑ Tracy <br />Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br />+ EH 13.24 1 REV. 1/ 9 5 ) <br />EH 14.20 <br />FEE <br />INFO <br />AMOUNT DUE <br />AMOUNT REMITTED RECEIVED BY <br />DATE <br />PERMIT' NO. <br />�L, <br />Q'`7 <br />