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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT it <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 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. �f <br /> Job Address <br /> City Lot Size PM <br /> II� <br /> I Owner's Name Address 7 � f s! , C .� <br /> ... dj!3:•� Phonea�s���„�"] <br /> Contractor [✓ Address License No.a2d5�S_Ad� PhonlM <br /> TYPE OF WELL/PUMP: KEW WELL El WELL REPLACEMENT ❑ DESTRUCTION {f <br /> f PUMP INSTALLATION ❑ SYSTEM REPAIR Q OTHER ❑ <br /> f t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWERLINES 'OISPOSAL FLO. PROP. LINE <br /> FOUNDATION _ AGRICULTURE WELLOTHER 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 /> IJ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing-__ Specifications - bi <br /> f 1 Public �✓ ( 1 Other Cl Delta Depth of Grout Seal <br /> Typo of Grout. <br /> I I Irrigation _Approx. Depth 11'fastefn­ Sdiface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction LJ Well Diameter Sealing Material Itop 50'1 <br /> Depth Filler Material (Below 50') <br /> TYPE_OF SEPTIC-WORK:_NEW-INSTAE ATION I 1 REPAIR/ADDITION I DESTRUCTION E I (No septic system permitted if public sewer is. <br /> availabie.within_ 200 feet.) <br /> Installation will serve: esidence_ Commercial— Other + <br /> Number of living units: ber of bedrooms <br /> Character of soil to a depth of 3 feet: er ta�depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �M <br /> PKG. TREATMENT PLT. ❑ Methodrof Disposal <br /> r <br /> Distance to nearest: Well tion Property Line <br /> LEACHING LINE . ❑ Na. & Le rues I length/size' SIM <br /> FILTER BED C1Distance to nearest: Well Foundation erty Line <br /> SEEPAGE PITS I I Depth Size Number I� <br /> SUMPS ❑ Distance to nearest: Well Foundation Property tine �� �+ <br /> DISPOSAL PONDS E1i <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. !y <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 all for all require -ns ctions. Complete drawing on reverse side. <br /> Signed X Title: <br /> Date.n� � `5/ <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ! - DateI <br /> Area <br /> Pit or Grout Inspection by Date.-_ M Final Inspection by ` Date <br /> Additional Comments: r- <br /> ❑ Stk 466-6781 IJLodi -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 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CACK RECEIVED BY DATE PERMIT`INO. <br /> EH 13-24 rs <br /> -21IREV.ti5) SH <br /> .� <br /> EH 114-26 �. [lll 111V'UfC` "C1,�`ll � 1"41 <br /> �I <br />