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APPLICATION FOR PERMIT <br /> 4 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E' HAZEL I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ` (Complete in Triplicate) <br /> Application is hereby madetothe 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 /> i` Local Health District. =a ' <br /> # CJ 3 h- rt Y�r City S� d Lot Size ��� J� Tc>~" PM <br /> Job Address <br /> Owner's Name / Address .?CA -41 Pik ��'` Phone G G <br /> i <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ <br /> I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> t , <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ' ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 flQ <br /> Depth Filler Material /Below 50'} r�� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIR/ADDITION ❑ DESTRUCTION (No septic <br /> iwi system <br /> feetitted if public sewer.is lf' <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms i <br /> Character of soil to a depth of 3 feet: i ' Water table depth <br /> F. SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Weil Foundation Property Line <br /> r- I <br /> # <br /> { LEACHING LINE LJNo. & Length of lines -Z Total length/size <br /> g* <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size = Number j <br /> SUMPS ❑ Distance to nearest: Welt , Foundation Property Line <br /> DISPOSAL PONDS ❑ ` I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance witti San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. t <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 /> L 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." q s <br /> The applicant must call for all required inspections. Complete drawing on reverse side._,,,'.. f <br /> ` 'Date: — .L 6—Y� <br /> Signed Title: O `r <br /> F <br /> Y FOR DEPARTMENT USE ONLY G- <br /> Application Accepted by µDate � / Area 2-4 -- <br /> Pit or Grout Inspection by y Date Final Inspection b Date 3�/ <br /> Additional Comments <br /> i ❑ Stk 466-6781 ❑ L i 369-3621 ❑ Mante 823-7104 ❑ Tracy 8354= <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,.P.Q. Box 7009, Stk.,-CA 95201CK <br /> w , <br /> FEE AMOUNT DUE AMOUNT REMITTED ;jCAZSHRECEIVED 8y DATE PERMIT'NO.INFO+EH 13-24(REV.i/a s} � C.J ��. Q <br /> i <br /> EH 14-28 _ <br />