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M " APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 Q ` <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �� <br /> (Complete in Triplicate) t <br /> k <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 /> I 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 /> t <br /> Local Health District. j �""7 ,-1 <br /> i City 5-TOCIA1 Lot Size jaD PM <br /> a Job AddressIJ7 44— <br /> Owner's Name <br /> Address _�?�`"Y Phone <br /> Contractor <br /> Address License No. _ Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> i 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 Weil Excavation Dia. of Well Casing {r, <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications V <br /> Fl Public 1-7 Other ❑ Delta Depth of Grout Seal Type of Grout-—­ <br /> 1 <br /> I 3 Irrigation _._Approx. Depth l I Eastern Surface Seal-Installed by - 1� <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done r <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIRIADDITION ( I DESTRUCTION ,(No septic system permitted if public sewer is <br /> .available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other \ <br /> M Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: - Water table depth <br /> I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: +Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> k� FILTER BED ❑ Distance to nearest- Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <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 /> I 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 st call for all squ <br /> ired inspec ions. Complete drawing o arse side. <br /> SignedXD /r w Title: ` , Date: <br /> T OR DEPARTMENT USE ONLY <br /> 11Area <br /> Date <br /> Application Accepted by / <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 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 MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INF ^'� r/.0 [ <br /> ♦.EH 13-24(REV.1/85) rn - 1 ✓ S �V� `�-C" (r"r� / 0— <br /> EH <br /> ✓• t/` ���� <br /> EH 14-2e V lJ <br />