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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ;,.;o ,. , , _,m,, (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 Slppllcatio u s <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations oaq <br /> Local Health District—;...r►l s L-;: ;1 - <br /> /Il 377 d-� GOA' M—C& R,-D— City Vs Lot Size PM <br /> Job Address � <br /> FL/✓ T­.a _ Address Phone <br /> Owner's Name O <br /> Contractor <br /> Address License No. Phone <br /> S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> -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 /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial <br /> El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Spec cations <br /> d Domestic/Private ❑ Gravel Pack F1 Tracy Type of Casing Type of Grout <br /> D Public ❑ Other [I Delta Depth of Grout Seal <br /> ❑ Irrigation _--Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done 1-1Typeof Pump H.P. State Work Done <br /> Well Destruction Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Cl DESTRUCTION INailabpti System <br /> permitted if public sewer is <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 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> r <br /> r LEACHING LINE ❑ No. & Length of lines Total length/size <br /> j FILTER BED ❑ Distance to nearest: Well_ Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS 17 Distance to nearest: 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 /> E ertify that in the performance of the work for which this permit is issued, l shall not <br /> Home owner or licensed agent's signature certifies the following: "I c <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 6inspections. Complete drawing on reverse side. <br /> ' �.�✓ 7�,��� Title: �Lr Date: IL-2—Signed X <br /> FO D PARTMENT USE ONLY <br /> o Date � � Ara <br /> Application Accepted j l,�I ,db <br /> Data Final Inspection by Date <br /> Pit or Grout Inspection y �,,}�� <br /> Additional Comments: 4" <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 + <br /> F <br /> �OC FEE K RECEIVED BY DATE PERMIT NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED <br /> +EH 13-24iREV.1/55) c�t7 <br /> ` EH 14-28 s� ,� <br />