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k <br /> APPLICATION FOR PERMIT _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED WA ' <br /> (Complete" in Triplicate) � <br /> Ap <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 applicatid s <br /> made in compliance with San Joaquin Cunty Ordinance No. 549 for sewage or No. 1862 for,weil/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 4 "tij <br /> City -Lot Size PM n <br /> Owner's Nam Address <br /> W�4 <br /> Contractor . Address �r��'J Q/ I-cerue �,�g&�1�9�Pon y� <br /> _ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ - WELL REPLACEMENT ❑ DESTRUCTION F) <br /> PUMP INSTALLATION ❑ :• SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK -SEWER LINESl" '. DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AG#iICULTURE WELL OTHER PITS/SUMPS _ <br /> INTENDED USE TYPE OF,WELL PROBLEM AREA CONST SPECIFICATIONS <br /> ❑ Industrial D Open BotIom r,_ .❑ Manteca.__ Ia_of.Well.Excavation Dia. of Well Casing <br /> �D Domestic/Private ❑ Gravel Pack }❑ Type of Casing Specifications <br /> FI 1 Public f 1 Other ^1l.Delto -i Depth of Grout Seal Type of Grout <br /> I ! Irrigation rox. Depth I 1 "E1sternl Surface Seal Installed by <br /> Repair Work Done Type of Pump <br /> H.P. state Work Done <br /> Well Des eon ❑ Well Diameter Scaling Material (top-50') <br /> Depth <br /> -'-Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW,INSTALLATION [1 REPAIR/ADDITION I DESTRUCTIONNo septic system permitted if public sewer is i <br /> -available within 200 feet.l <br /> installation will serve: Residence=t Commercial._ Other E - ) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: r — Water table depth t 16 <br /> SEPTIC TANK EJType/Mig Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ f f t <br /> � sS, Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> �1, <br /> LEACHING LINE ❑ .No. & Length of lines 0.•m- =- <br /> - Total length/size <br /> FILTER BED C] Distance to nearest: Well Foundation Property Line <br /> 3 <br /> SEEPAGE PITS., I 1 Depth Size b Number <br /> SUMPS � L� Distance to_?hearest: Well 'Foundation Property Line <br /> DISPOSAL PONDS ❑ f <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, ander <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or lice»sed agent's signature certifies the follow ig: 'TI`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: "I certify that in the performance-of-the work-for-wHich this permit is-issued, 1,shall employ persons subject to workman's compensa-. <br /> tion laws of California." <br /> The applican st call for all required ' tions. Complete drawing on r e si <br /> Signe t`t Title: <br /> Date: <br /> �! �( <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by Date y^\ y� Area <br /> Pit or Grout inspection byDate i Final Inspection by pate <br /> Additional Comments: _ ©os ~ S C)69, — �99 `)81 /s N 9 <br /> ❑ Stk 466-6781 Q Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385Q u ,-L S.. R <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.'.Hazelton Ave., P.O. Box 2009, Stk., A 95201 <br /> FEE i1 <br /> CK 0 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. <br /> + EH 13-24(FI EV.+/K51 <br />