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�! APPLICATION FOR PERMIT <br /> I <br /> SAN JOAMIN LOCAL HEALTH DISTRICT <br /> I` 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> li PERMIT EXPIRES-1 YEAR FROM DATE ISSUED <br /> ioL (Complete in Triplicate) „ <br /> I Application is hereby made taithe 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. y <br /> c � 1 * � R+ f s <br /> I Job Address 2 4 I �'P, �Q <br /> k �City to talV Lot Size PM <br /> 41 <br /> Owner's NameLl ZZ I YYA e Address Phone <br /> e <br /> F Contractor Address License No. Phone <br /> 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 />! ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout +R f <br /> ❑ Irrigation L Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done A <br /> Wel! Destruction ❑ WeI! Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is '+ <br /> available within 2 feet.) <br /> Installation will serve: Re 'de a Commercial_ Other f <br /> Number of Irving units: Number of bedrooms °�._. � r � 6 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg r Capacity % No. Compartments <br /> PKG. TREATMENT PLT. ❑ it 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 <br /> fl <br /> SEEPAGE PITS Il Depth Size Number If I <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> ISPOSAL 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 mu t call for all required inspections Complete drawing on reverse side. <br /> V IjSigned I s1 Title: Date: <br /> l� # <br /> - <br /> �FOR �PARTM�ENTUSE ONLY �] <br /> Application Accepted by Date U`` tJ� Area Q <br /> Pit or Grout Inspection b Date Final Inspection by na►- <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑ Lodi, 369-3621 ❑ Mante 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 AMOUNT DUE AMOUNT REMITTED RECEIVED BY <br /> INFO DATE PERMIT NO.. <br /> + EH 3-2A IREV,iia 5) <br /> 7 <br /> EH 14-28 <br />