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APPLICATION FOR PERMIT y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (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 application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1962 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address City /�¢ C•¢ Lot Size PM -— <br /> Owner's Name <br /> Ys C ®�G Address Phone <br /> � t <br /> Phoned <br /> Contractor Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEM1/TENT"❑—DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Q !--- <br /> DISTANCE <br /> - <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES *�`s DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL- PITS/SU <br /> MPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIOWSPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom_ ❑ Manteca, Dia.,of Well-Excavation Dia. of Well Casing <br /> ❑ Domestic/Private J ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> iTl Public F1 Other n Delta Depth of Grout Seal Type of Grout - <br /> I ( Irrigation -.Approx. Depth I I ! Eastern Surface Seal Installed by <br /> Repair Work Done LJ Type of Pump H.P. <br /> State Work Done `. <br /> Well Destruction ❑ Weil Diameter Sealing Material stop 501 p 1 <br /> Depth - ..Filler Material.IBelow 50'1 - <br /> TYPE OF SEPTIC WORK: - NEW'INSTALLATION 1.1 REPAIR/ADDITION?t-DESTRUCTION I I (No septic system permitted if public sewer is j <br /> available within 200 feet.) <br /> - I d <br /> Installation will serve: Residence— Commercial— Other <br /> a <br /> Number of living units: Number of bedrooms E <br /> Character of soil to a depth of.3 feet: r Water table depth � <br /> SEPTIC TANK ❑ Type/Mfg Capacity °° No. Compartments f <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> pistance to nearest: Well Foundation Property Line i <br /> S. <br /> LEACHING LINE K_ i No. & Length of lines Q Total length/size <br /> FILTER BED ❑ Distance to nearest: Well_ 16-4 _Foundation, O tF Property Line fO1101- <br />` SEEPAGE PITS I I Depth Size Number <br /> SUMPS 0 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: "I certify that in the performance of the work for which this permit is issued, I shall not <br />'I 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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of.California'-'-,_ . —---yam . - -�� — -' - <br /> The applicant mu all for all r uired i spections. Complete drawing on reverse side. <br /> Signed X <br /> Title:' £',S751,-��- -�� &-Date: Z-"2 Qd' <br /> NT USE ONLY <br /> Application Accepted by Date 0" Area <br /> Pit or Grout Inspection by Date Final Inspection by i7 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> j 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 REMITTEDGASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> 6 EH 1324 1REV.1/H 51 V V �O }'] r� r {tJ 0 <br /> EH 14-28 <br />