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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 /> (Complete in Triplicate) <br /> 6 <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 Ryles and Regulations of.the San Joaquin <br /> Local Health District. i <br /> Job Address �� V` ti �y' �- ��City Lot Size PM - <br /> Owner's Name _ �` "ti-� - Address 2�, Phone' J <br /> Contractor ,Da r Address L��6",License N'o2c& 37 i6f -'— Phon Pie T+ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION X 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 i <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 <br /> ❑ Irrigation _—Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done: E:) Type of Pump tea <br /> H.P. ���2� State Work Done � ne� <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 ; <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is N <br /> available within 200 feet.) r <br /> Installation will-serve: Residence_ Commercial_ Other 0 <br /> Number-of living units: Number of bedrooms <br /> -�­1Cha`raqter of soil to a depth of 3 feet: Water table depth ; <br /> SEPTIC,TANK ❑ Type/Mfg 41C�pacityNo. Compartments t` t <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> f Distance to nearest: Well Foundation Property Line <br /> LEACHING LINEI ❑ No. & Length of linesTotal length/size <br /> FILTER BED ❑ Distance to nearest: Well / Foundation Property Line <br /> SEEPAGE PITS"''-' E1-'-Depth_ Sizei Number ' <br /> SUMPSO Distance to nearest: Well _Foundation__ Property_i e <br /> LD <br /> DISPOSAL PONDS r: x - _ <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 /> 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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must 11 for all required-inspections. Complete drawing on reverse side. ,/ <br /> Signed Title: -s��- _ Date: 1 �7 0 <br /> y�,, OR DEPARTMENT USE ONLY <br /> Application Accepted by %�,'v4/lf/F _ Date Area <br /> Pit or Grout Inspection by Date Final <br /> /Ins/p/ection <br /> �Tlbyy Date <br /> Additional <br /> Additional Comments: _ !f_ �D�IGZ� � v"�S` v�P7/� ��`� 44*tlA _ <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 T FO Manteca 823-7104 I] Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE.;: AMOUNT REMITTED CK* RECEIVED BY DATE PERMIT"NO.- <br /> INFO CASH <br /> + EH13-24(REV.1 8 5) �b <br /> EH 1426 ` !q`T -amu`jO <br />