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� ---- ;wry-----��-�, <br /> !� APPLICATION FOR PERMIT �. . <br /> e I " <br /> r,J <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA NiOW L"A"V,•- <br /> f V �( Telephone (209) 466-6781 <br /> 4 G y>^ 0�+fi P RMIT EXPIRES 1 YEAR FROM DATE ISSUED '""`"`A <br /> (Complete in Triplicate) lrnb Apk�AP, <br /> i <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 /> i 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 /> s <br /> Job Address City79 0.s~Xt� Lot Size � / PM <br /> Owner's Name ,?04VAIDC771� 2ACG/9R Jr' ( Address li L-Ex-1 <br /> � Phone <br /> -Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: .NEW WELL-171, Wi.LL REPLACEMENT ❑ DESTRUCTION ❑ r <br /> PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER D <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER W PITS/SUMPS _ <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR PECIFICATIQNS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca la- of Well Excavation Dia. of Well Casing r <br /> ❑ Domestic/Private ❑ Gravel Pack Type of Casing Specifications �^ <br /> C] Public C1 Other I Cl Delta Depth of Grout Sea] Type of Grout <br /> -- <br /> t <br /> I Irrigation <br /> g Pox_. <br /> Depth I I Eastern Surface Seal Installed by <br /> Re air Work Done T t '(0 <br /> p ype of Pump H.P. State Work Done_ <br /> Well Destr ❑ Wel! Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Belo w 501 <br /> TYPE OF'SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION I I DESTRUCTIONl i(No septic system permitted if public sewer is <br /> } + available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other F- - <br /> r <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:) 3 Water table depth <br /> SEPTIC TANK _ ❑ Type/Mfg; Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ * Method of Disposal <br /> Distance to nearest: Wel! Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS D Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ -4 4 <br /> I hereby certify that i have prepared this application and that the`w_ork 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 /> The applicant Wst call for all required ins coons: Co late drawing on reverse side. ) <br /> Signe` X Title: Date: �� v <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by Date r. 1 -577 Area <br /> Pit or Grout Inspection by Date_ p-} <br /> _ Final Inspection by Date - '2 Z�5 <br /> Additional Comments: �-Y-- <br /> ❑ Stk 466-6781 EDLodi - -3621 ❑ Manteca 823- ❑'Tracy 635 6365 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r I <br /> FEE AMOUNT DUE AMOUNT REMtTTEO CK 0 INFO RECEIVE[) BY DATE PERMIT'NO. <br /> ZZ <br /> + EH 1 -241REV.irks} !0U <br /> EH 7426 . C�/ <br />