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7 <br /> 3 <br /> i APPLICATION FOR PERMIT 4 <br /> SAN JOAQUIN LOCAL,HEALTH DISTRICT <br /> i 1601 E. HAZE T ON AVE., _STOCKTON, CA <br /> t Telephone (209),466-67$1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> oaquin Local Health District for a permit to construct and/or install the work herein described..This application is <br /> Application is hereby made to the San J <br /> ounty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of,theiSan Joaquin <br /> made in compliance with San Joaquin C <br /> 3 .. br, - <br /> Local Health District. w ,.-,p ` 'r A .�.."~ <br /> z 7/.f :;1���prs`,.. 6ZCfJ t City Lot Size PM.a <br /> Job Address , . . .; t.e ✓W .0 �: . <br /> i <br /> Owner's Name Address " - Phone - <br /> - <br /> License No. / Phone <br /> Contractor Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ <br /> ' 11 <br /> PUMP INSTALLATION ElSYSTEM REPAIR 11OTHER EJDISTANCE TO NEAREST: SEPTIC TANK 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 /> Dia. of Well Casing <br /> ❑ Industrial "­� ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of CasingSpecifications <br /> ❑ DomesticlPrivate 13 Gravel Pack EJ Tracy yp Type of Grout <br /> i ❑ Othler ❑ Delta Depth of Grout Seal <br /> ,❑ Public � C v <br /> ❑ Irrigation ' ---Approx. <br /> Depth E71 Eastern Surface Seal Installed by [" <br /> --_.' �..._-- �-,p H.P. State Work Done <br /> f Repair Work Donee O Type of Pump <br /> Well Destruction i ❑ Well Diameter Sealing Material (top 501 <br /> Depth <br /> Filler Material (Below 501 ` <br /> TYPE OF SEPTIC�WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial Other D <br /> Number of living units: Number of bedrooms ! <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line y i <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> l FILTER BED ❑ Distance to-nearest: Well _- Foundation Property Line <br /> t � <br /> SEEPAGE PITS - ❑° Depth Size Number <br /> �� <br /> SUMPS ElDistance to.nearest: Well 3' Foundation `� I Property Line <br /> DISPOSAL PONDS 1-1Y <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 /> I <br /> rules and regulations"of the San Joaquin Local Health District. # t <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 iin such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> certifies the following:"I rtify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensai <br /> tion laws of.California." t , <br /> The applicant mEust r -r uire coons. Complete drawing on reverse side. <br /> Signed Title: ` Date: <br /> A F R DEPARTMENT USE ONLY <br /> /�..1. s Date -&-I q-W Area ~ <br /> Application Accepted by - <br /> + * 'Date Final Inspection by Date <br /> Pit or Grout Inspection by IQ f� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 © Tracy 83rr6365 <br /> Applicant'Return all `copies to Environmental Healih'Permit/Services 1601 E.-Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK# RECEIVED BY DATE. ;RMIl"`NO. <br /> lNFO AMOUNT DUE t AMOUNT REMITTED CASH <br /> tV <br /> +EH 13-24(REV.I/A 5Y M l.J - - <br /> a EH W28 fff <br />