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APPLICATION FOR PERMIT <br /> K <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1 l 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-67$1 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) r !f�'� '► <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 Rules and Regulations of the Sari Joaquin <br />' Local Health District. <br /> i f - <br /> 4LJobAddress LL /�/ / C- z -- City Lot Size PM <br /> er's Nam i' "c- SAddress �� z�'�`� � �yl . Phone g'tractor Se-1 Address License No. Phone <br /> TYPE OF WELL/PUMP:. NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL ITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPE ON5 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of avation Dia. of Well Casing <br /> ©Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casing Specifications <br /> ❑ Public ❑ Other elta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation rox. Depth I ]Eastern Surface Seal Installed by <br /> i <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> f Weil Destruction ❑ Well Diameter Sealing Material (top 50') <br /> t Depth ­Fillef-Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION IJ DESTRUCTION^No septic system permitted if public sewer is <br /> I ailable within 200 feet_.) <br /> I Installation will serve: -Residence� --Commercial~. other f <br /> Number of living units: Number of bedrooms J <br /> Character of soil to a depth of 3 feet: Water table depth k + <br />{ SEPTIC TANK ❑ Type/Mfg �E Capacity No. Compartments ' <br /> l PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: f Well t Foundation Prop"drty.Line <br /> LEACHING LINE ❑ No. & Length of lines t 'ti- I -AVt,Total length/size <br /> FILTER BED ❑ Distance to nearest: <br /> Well' Foundation Property Line <br /> SEEPAGE PITS I I Depth f Size l Number <br /> i <br /> SUMPS ❑ Distance to nearest: -v Well- Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have.prepared jhis'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 taws 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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m fora d inspec ns..-Complete drawing on reverse side.--- <br /> ... /� <br /> ned X Title: Date: , <br /> �jf,C/Y✓� FOfi DEpARTMENT-USE ONLY <br /> r Application Accepted by ^^ Date 0 Area <br /> ` L <br />� Pit or Grout Inspection by Da Final Inspection by�. G_..�C.�„ Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ L di 369-3621 ❑ Manteca 823-7104 ❑ Tracy —839'639t- <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE Fr <br /> F INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERNII7 N0. <br /> I EH 13-24(REV.It 115) 00 <br /> EH 14-26 - ✓✓✓ cx _ <br /> i <br />