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Al <br /> APPI„L CTM FOR .. <br /> SAN JOAQUIN LOCAL HEAM4 DISMICT <br /> 1601 E. HAZELTON 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 fora permit to construct and/or install the work herein described.4 is application is <br /> made in compliance with San Jo OuntVOrdinenm 0f for sewage or No.1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. 04_*ns AL-A,0c <br /> Job Address �'7 ��"� �16 <br /> A/�� C rf city Lot Size PM <br /> Owner's Name �lO 41�/ ess 7' Phone <br /> Contractor Address License No. — Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO Al7.e <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ � -11—d <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.LINE /e'l .}. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. ofWellExcavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Speoificetiona <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑`Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <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. ❑ MetheIT-of Disposal <br /> Distance to nearest: Well 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 ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property,Line <br /> DISPOSAL PONDS ❑ <br /> I 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 f±fealth 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."Contractor's hiring or sub-contracting signature <br /> certifies the following:"1 certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensS- <br /> tion laws of California. <br /> The applicanimust call for aU r uired inspections. Complete drawing on reverse side. <br /> Signed X elk-/ Title: Date: , <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date a JArea <br /> Pit or Grout Inspection by Date Final Inspection b,�7 Date_[ r <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369 621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 <br /> Applicant-Return all copies to: Env onmental Health Permit/Services 1601 E.Hazelton Ave., P.O. Box 2009,Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT"NO. <br /> INFO 11'k <br /> +EH 13-24(REV t/95) ' � O d /Y � er <br /> EH 1428 t..JC- <br />