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APPLICATION FOR PERMIT <br /> SAN JOAQUIN 'LOCAL HEALTH DISTRI& - <br /> �� E. HAZEL ION�AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 u <br /> PERMIT EXPIRES i YEAR rFROM 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 /> I Local Health District. <br /> Job Address �� � lam. Mlc C>EL/ �' City Lot Size PM <br /> Al <br /> Owner's Name Address Phone _7119 <br /> 1 Contractor Address <br /> 3�E25P <br /> 4.. se No. 3 Phone <br /> TYPE OF WELL/PUMP: V NEW WELL X WELL REPLACEME T DESTRUCTION El <br /> PUMP INSTALLATION Ll SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 116* PROP. LINE �I <br /> - —FOUNDATIONS - ' -•"AGRICULTURE-WELL OTHER WELD PITS/SUMPS: _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L <br /> N <br /> ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing <br /> XDomestic/Private X Gravel Pack 13 Tracy Type of Casing P V6 Specifications r <br /> ❑ Public ❑ Other t ❑ Delta Depth of Grout Seal ! Type of ut <br /> y C! Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> I Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> I Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth I. 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 � <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. ❑ 'f 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 ❑ Depth *I Size Number <br /> _ SUMPS _ ❑ Distanceto_nearest: Well Foundation Property Line__ <br /> DISPOSAL PONDS ❑ <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 /> 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."Contractors 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 /> k The app- n must call for all reqinspect ns. <br /> Signed Com wi on reverse side., <br /> f Date: / ' <br /> e r i e <br /> fl. <br /> n °' R OE RTMENT USE ONLY <br /> - <br /> Application;Acceted by Date Area <br /> e�+wisrrw <br /> Pit or Grout Inspection by I '" e-11 Ll x-24,_ Date Final Inspection by ' Date <br /> Additional Comments: L. <br /> ❑ Stk'..466-6781<:., ❑ Loei 369-3621 ❑ Manteca SM-7104 ❑ Tracy 835-6385 <br /> Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 <br /> a ,3 <br /> 4, INFO AMOUNT DUE. AMOUNT REMITTED C K RECEIVED BY DATE: PERMtT`NO. <br /> +EH 13-24(RPV.1/s 5) <br /> EH W26 . "C1 c"� 1�� Y m 3/ 6-s-Alot <br />