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` - APP LICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E f <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> L <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 /> l 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. r� <br /> rJobAddressCity Lot Size PM <br /> er's NameIAIj� , Address ' .��. Phone <br /> 01 <br /> ractor AddressP� Lit erase Nv. Phone <br /> TYPE OF WELL./PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ` <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 1 OTHER ❑ 3 <br /> DISTANCE TO NEAREST: SLPTIC TANK.. SEWER LINES DISPOSAL_ FLD. .- INE <br /> FOUNDATION AGRICULTURE WELL-,- ' 0 �PITSISUMPS <br /> INTENDED USE TYPE OF WELL,-.-�-PROBLEM AREA UCTION SPECIFItrATIONS `t ' <br /> ❑ industrial ❑:Open Bottom . ❑ M Dia. of Well Dia. of Well Casing <br /> r <br /> i ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing X Specifications <br /> 1-1 Public ❑.Ot ❑ Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation _..Approx. Depth I 1 Eastern Surface Seal Installed by - <br /> Repair Work D ❑ Type of Pump H.P. State Work Done <br /> Well Destructio ❑ Well Diameter Sealing Material Itop 50'1 <br /> Depth Filler Material (Below 501 t <br /> TYPE OF SEPTIC'WORK: NEW INSTALLATION I1 REPAIR/ADDITION i I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> t&iallation will serve: Residence— Commercial— Other t /� <br /> Number of living units: Number of-bedrooms <br /> Character of soil to a depth of.3 feet: Water table depth <br /> t SEPTIC TANK Cl Type/Mfg Capacity No. Compartments <br /> ' PKG. TREATMENT PLT. ❑ ' Method of Disposal <br /> .Distance to nearest: Well Foundation Property Line f <br /> r' <br /> r <br /> LEACHING LINE ❑ No. & Length of fines Total length/size '1 , <br /> ( FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I t ' Depth Size Number <br /> SUMPS -1 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 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 became subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> i certifies the following: I certify that in the performance of the work for which this permit is issued,l shall employ ersons subject to workman's com ensa- <br /> " pe P P YP l P <br /> tion laws of California." rq i <br /> i he applicant must call for all required inspections. Complete drawing on reverse.side <br /> Signed X r Title: _I �suf... -.. , ` Date: <br /> FOR DEPARTMENT USE ONLY E <br /> Application Accepted by �"''�" "" — Date Area / <br /> Pit or Grout Inspection by r Date Final Inspection by Date <br /> c r Additional Comments: rY <br /> © Stk- 466-6781— - L7 Lbdi-'=369-3621 A"[1 Manteca� 823-7104_­ CJ Tracy �835-6385 H <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE ~AMOUNT REMITTED "ECIC` RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> +.EH 13-24(REV.1/n 5) <br /> EH 14-26 <br />