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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL'HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Com lete in Triplicate) Y �o <br /> R <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 Ryles and Regulat''Qns of the San Joaquin <br /> Local Health District. I -'. �. „ J <br /> {6- I iy G�4 /PM <br /> Job Address ��(hLL i [ City Lot Size. <br /> Owner's Name Address 17{6611 a�• L�7�QLt/�c hone <br /> Contractor Address -T5- hR&Aa4 /1 License No.�I��3__ Phone <br /> TYPE OF WELL/PUMP: V NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK l00 SEWER LINES DISPOSAL FLD.Z49 PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS C� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONP 10 <br /> C1 Industrial Ll Open Bottom El Manteca Dia, of Well Excavation Dia. of Well Casing <br /> Domestic/Private Gravel Pack ❑ Tracy Type of Casing pV Specifications <br /> ❑ Public El Other ❑ Delta Depth of Grout Seal Typg of Grou <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by LLL I <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. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> - S <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 r <br /> DISPOSAL PONDS w ❑ <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 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 Cal'ornia." <br /> The appli a ust call for all requi4 inspections. omplete drawing on a rse side. <br /> Signed Title: t Date: <br /> FOR DEPA MENT SE ONLY a ' <br /> Application Accepted by Date < / Area D� <br /> Pit or Grout Inspection by Date Final Inspection b Date — -r <br /> Additional Comments:_ <br /> ❑ Stk 466-6781 p Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant=Return all copies to:;Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT`NO. <br /> INFO CASH <br /> +EH 13-24(REV - / ` <br /> EH M26 �� '� 7J �q . <br />