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APPLICATION-FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE:; STOCKTON, CA <br /> N Telephone 1209) 466-6781 <br /> PERMIT EXPIRES 1 SYEAR FROM DATE ISSUED <br /> „ i., {Complete in Triplicate) <br /> I 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. 1852 for-well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Joh Address Ci Lot Size pM <br /> Owner's Name � / V <br /> drFae Phone - - <br /> Contrac or 3 Address License Noc�Y��9 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 /> ❑ Ind ial ❑ Open Bottom. Manteca _ �Dia._of,Well„Excavation __- _ Dia.-of-Well Casing i <br /> omestic/Private ❑ Gravel Pack ❑ Tracy -Type of Casin- <br /> 9 =� f Specifications <br /> ❑ Public ❑ Other ❑ Delta r Depth of Grout Seal Type of Grout <br /> ❑ Irrigation —Approx, De h-..-.© Eastern•*= =)—hfac`e�eal called by --x-4Y-* - r `� <br /> Repair Work Done ❑ Type of Pum _ H.P. °r. State Work Done q ` <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') n>” ,if � <br /> Depth I Filler Material (Below 50'I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system„perinitted if.public sewer is <br /> available within 200 feet.) i <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:I Water table iiepth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments j <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line i A <br /> � � + ry <br /> LEACHING LINE ❑ No. & Length of lines Total length/size I <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line tF <br /> .M <br /> SEEPAGE PITS ❑ Depth Size Number j t <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line i <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 District. .. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this emit isfissued, I shall not <br /> employ any person in such manner as io 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 t e work for which this permit is issued, I shall employ persons subject to workman's compensa- f <br /> tion laws of C rnia." ' A� -� k <br /> The applican m st call for all required in cti s. Co plete drawing on rse side. <br /> 9 <br /> Si ned Title: `� r"'*. Date* , / <br /> FOR DEPARTMENT USE�ONLY� <br /> Application Accepted by '`Date f 3� Area <br /> Pit or Grout Inspection by Date r Final Ins ` <br /> petion by Date <br /> \ <br /> Additional Comments: ' <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 *sZ p Tracy :835-5385 , <br /> Applicant- Return_ all copies to: Environmental Health Permit_/Services 1601 E. Ha.zalton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE CK <br /> ' k <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH/ RECEIVED BY ! <br /> DATE PERMIT NO. <br /> EH1 -241REV.i/a51 <br /> EH,420 <br /> i <br />