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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT i <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) I` <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 s <br /> Local Health District. a. <br /> I <br /> Job Address City Lot Size ' PM <br /> I� 1 <br /> LOwner's Name Address Phone I '�+ 1 <br /> i! <br /> swContractor Address_N6 // License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑a <br /> DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES DISPOSAL FLD. PROP. LINED( <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I <br /> INTENDED USE Tl' OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.;of Well Excavafiori Dia. of Well Casing <br /> ;<Domestic/Private ❑ GravelPack © Tracy Type of Casing Specifications , <br /> I'1 Public ❑ Other Ll Delta Depth of Grout Seal Type'of Grout <br /> I i Irriflation� _,.Approx. Depth l I Eastern Surface Seal Installed by �— w aL <br /> "{W} <br /> Repair Work Done ❑ Type of-Pump-; �—H P__ IA w.. _ �a1te Work Done <br /> Well Destruction El Well Diameter t t _ Sealing Material Itop 50'1 <br /> :.Depth _ ..7°1i� Filler Material (Below 50`) <br /> TYPE'OF-SEPTfC-WO1RK: NEW INSTALLATION 1.1 REPAIR/ADDITION i.l DESTRUCTION i l "(No septic system permitted it public sewer is ` <br /> available within 200 feet.I r <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 1 <br /> SEPTIC TANK ❑ Type/Mfg y' Capacity No. Compo ments <br /> ' PKG. TREATMENT PLT. ❑ "? J Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line - ' p <br /> 'l <br /> SEEPAGE PITS 11 Depth Size _ Number JJII� <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> k DISPOSAL PONDS -❑ ��- - — .`r ! _ `�_=� t <br /> 4, <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. '11' <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 pe. o in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the fo owi g: "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. lif nia", <br /> The appli t ust tali for all r quired inA;c1ionComplete drawing on r v se side. _ II <br /> I I <br /> Signed X Titre:- n Date: 70 <br /> DEPA TMEfVI_USE_ONLY.._._._ <br /> Application Accepted by Date s Q Area <br /> I Pit or Grout Inspection by Date Final inspection by Date �L <br /> 1 Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 0 Tracy' 835-&385, <br /> Applicant• Return all copies to: Environmental Health Permit/Sanlices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED 8Y DATE 1 PERMFIT NO. <br /> _-- <br /> +.EH 13-241REV.1i85) I�-/ <br /> 31 <br /> EH 14-26 p` <br /> i .;I. <br />