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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T 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 made to the San Joaquin Local Health District for a permit to Anstruct 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 /> Job Address � / y/�� t✓ elv e( L/V City--- — Lot Size PM C <br /> Owner's Name �� c k1 Address Phone 36 <br /> �4Q1 Address 96 License No. Phone_ ` 4 <br /> Contractor >�/Sh 1t/ <br /> TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEM NT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O <br /> DISTANCE TO NEARS PTIC 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 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f'l Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth I 1 Eastern Surface Seal Installed by _ <br /> Repair Work Done O Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 v` <br /> Depth Filler Material (Below 501 �} <br /> TYPE Of: SEPTIC WORK: NEW INSTALLATION I 1 HEPAIR/ADDITIO DESTRUCTION I 1 INo septic system permitted if public-sewer is <br /> available within 200 feet.) ' <br /> r'it <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 r <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line ' <br /> LEACHING LINE Ir No. & Length of lines Total length/size 4/[? <br /> FILTER BED ❑ Distance to nearest: Well Foundation T Property Line <br /> SEEPAGE PITS Depth a S Size <br /> 33 Number <br /> SUMPS L� Distance to nearest: Well I&W rFoundationZZO Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 /> Signed X � l+-. 1-4a. L Title: S r Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 4f Date��r `� 14rea , <br /> XPi ar Grout Inspection by a e final Inspection Date(�z2eqP_F <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ 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 ,A(� <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT-NO. ` <br /> INFO CASH <br /> EH13.24 IREV.t/H 51 7 <br /> EH 14-28 V/) <br />