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APPLICATION FOR PERMIT 'S <br /> ' SAN JOAO,UIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE.;.STOCKTON, CA <br /> Telephone "(209) 466-6781 <br /> PERMIT EXPIRES'l YEAR`FROM DATE ISSUED <br /> r l <br /> (Complete in Triplicate) : , <br /> y,� :. .,.•,9 <br /> ;s <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 a 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. Ae 1 .:..Y) <br /> Af <br /> rr - City Lot Size PM l <br /> Jab Address [•� A <br /> Owner's Name <br /> Address License No, Phone <br /> Contractor _ <br /> TYPE OF WELLIPUMP: NEW WELL F] SYSTEM <br /> REPLACEMENT Ll DESTRUCTION El <br /> l PUMP INSTALLATION Q' SYSTEM REPAIR ❑ OTHER ❑ i <br /> DISTANC SEPTIC TANK: i SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDA AGRICULTURE WELL OTHER WI=LL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of ration <br /> Dia. of Well Casing <br /> T e of Casing' �` � � '�-F Specifications { <br /> ❑ Domestic/Private d Gravel Pack L] Tracy Type g T e of Grout i <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seat Yp <br /> ❑ Irrigation �4pprox. Depth ❑ Eastern Surface Seal Installed by r <br /> H.P. State Work Done_ _ <br /> Repair Work Done ❑ Type of Pump 1 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'i <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WOflK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION (Nailabpe1within 200 feet.) if public sewer <br /> r r <br /> l ' Installation will serve: Residence— Commercial— Other __ ..-r-• pp i. <br /> I Number of living units: Number of bedrooms <br /> Water table depth <br /> -Character of soil to a depth of 3 feet: <br /> Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg _ <br /> . �r <br /> PKG. TREATMENT PLT. ❑ 1 Method"of Disposal <br /> 1 <br /> � Distance to nearest: Well Foundation -1 -Property Line1 <br /> Total length/size 4 <br /> I LEACHING LINE ❑ No. & Length of lines c <br /> -� - I Property Line <br /> FILTER BED ❑ Distance to nearest: Well" Foun ation <br /> SEEPAGE PITS. ❑ Depth <br /> Size Number l " <br /> SUMPS ❑ . Distance to nearest: - Well Foundation --<._- --=Property-Line" <br /> DISPOSAL PONDS ❑ <br /> } l 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, 1 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 /> R tion laws of California." l <br /> The applicant u call for all required inspections. Complete drawing on reverse side. 57 <br /> tt Title: Date: <br /> K Signed X <br /> FOR RTMENTUS ONLY �7 i <br /> Date / Area <br /> Application Accepted by i�_ - <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date "_��o <br /> '"Additional Comments: -"- �_ a� <br /> - <br /> ❑ Stk 466 fi781 ❑ Lodi369 362823-7104 ❑ Tracy 835 6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.: CA 95201FEE _ <br /> CK RECEIVED BY' DATE PERMIT'NO. <br /> a INFO AMOUNT DUE AMOUNT REMITTED 1 SH � <br /> r EH 13-24 MEV.}/H 51 r A r// O G 7 <br /> EH 14-28 <br />