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APPLICATION FOR PERMIT _ <br /> SAN JOAQUIN LOCAL- HEALTH DISTRICT t <br /> ' 1601 E. HAZELTON AVE., STOCKTON, CA <br /> " "Telephone (209) 466-6781 <br /> PERMIT EXPIRES 9 YEARTROM DATE ISSUED <br /> _r. (Complete,.in;Triplicate), ,r- Y ,j <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 San Joaquin <br /> Local Health District. <br /> ell- <br /> Job Address ! AC D} �f;,. City Lot Size PM <br /> 1 <br /> Owner's.Name dress Ua Phone <br /> t r , <br /> Contractor Address License No. Phone { <br /> TYPE OF WELL/PUMP- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER'❑ r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O <br /> ❑ Industrial 1-1OpenBottom LJ Manteca Dia. of Well.Excavation.- Dia. of Well Casing p <br /> El Domestic/Private 71 Gravel Pack Ll Tracy ! Type of Casing Specifications �1 <br /> 1 <br /> ❑ Public ❑ Other ❑ Delta I Depth of Grout Seal C Type of Grout <br /> ❑ Irrigation ---Approx. Depth 4 ❑ Eastern Surface Seal.Installed by <br /> 3 <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 t I <br /> r � <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION tNo septic system permitted,if public sewer is j <br /> ' available within 200 feet) <br /> Installation will serve: Residence_ Commercial_ Other 1 <br /> Number of living units: Number of bedrooms E <br /> Character of soil to a depth of 3 feet: Water table depth j <br /> SEPTIC TANK Type/Mfg ' x_ Capacity I No. Compartments <br /> PKG. TREATMENT PLT. ❑ a Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length'of lines Total length I/size <br /> FILTER BED ❑ Distance to nearest: Well- Foundation _ Property Line <br /> SEEPAGE PITS ❑ Depth , Size Number r <br /> SUMPS ❑; Distance to nearest: r 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 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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> �J Signed X o Title: —�� Date: <br /> .- FOR DEPARTMENT USE ONLY <br /> Application Accepted by ► ` `-� Date Area a3 <br /> Pit or Grout Inspection b Date Final Inspection by Date 4, zZ <br /> Additional Comment Y3 <br /> ❑ Stk 466-6781 - ❑ Lodi -3621 LJMa teca 823-7104 ElTracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA':95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT*NO. <br /> + EH 13-241i1Ev.1/85) 3J �__ C <br /> EH 14-26 <br />