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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL,HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466 6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r <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 <br /> Local Health District. <br /> Job Address 7s ���'� ` �' • City L Lot Size F �6 9 PM <br /> Owner's NameAddress * e Phone V.440 /V <br /> Contractor P Address License No.J r��f Phone <br /> TYPE OF WELL/PUMP: EW WELL WELL REPLACEMEN EI DESTRUCTION ❑ <br /> PUMP INSTALLATION / SYSTEM REPAIR ❑ - OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES DISPOSAL FLO. AW PROP. LINE -10 �1 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL_66G ` PITS/SUMPS.450 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑Opeii 6oisoE1 kAarifeca" Dia. of-Well-Excavatiori.r -- Dia. of V1/eIf Casing: — <br />`��. P Domestic/Private g Gravel Pack ❑ Tracy Type of Casing—?vSpecifications ��8 <br /> 1­1 Public fl Other F1 Delta Depth of Grout Seal /�!)` Type of Grout gC)e /� <br /> I I Irrigation --Approx. Depth .I 1 Eastern Surface Seal Installed by M=,e - <br /> Repair Work Done ❑ Type of Pump _,_ H.P. $ State Work Done <br /> Well Destruction ❑ Well Diameter ;rSealing Material atop 50') <br /> Depth f. .,,,Filler Materiah(Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i .REPAAIWADDITION I-I, DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ O_Hier <br /> Number of living units: Number of bedrooms I <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. ❑ a Method of Disposal <br /> Distance to nearest: Well Foundation Property.Line ` <br /> ii <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: "Well Foundation Property Line f <br /> SEEPAGE-PITS . I 1 Depth Size Number <br /> t <br /> SUMPS Ll 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 Diltrict. <br /> Home owner or licensed agent's signature certifies the following: "t 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." Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the perfofmance 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 miuslcall.toLall re uired pe ions. Complete drawing on reverse side. J <br /> Signed Y. Title: �?--►� an�+—- Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ' <br /> A;4 Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO 6r- 0VE0 <br /> r.EH 13-241REV.F/H51 /�-� O� [ <br /> EH 1428 <br />