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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 <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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District` <br /> Job Address q i LJ TCS T; , <br /> ._ City Lot Size 7PM <br /> Owner's-Name 0)51ehuc A " '+ <br /> Address C? Phone S10 <br /> Contractor Address ;7-- License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL O 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 /> ❑ Industrial LJ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 3 ❑ Public ❑ Other 7 Delta Depth of Grout Seal Type of Grout <br /> Ll Irrigation <br /> ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction El Well Diameter 1.— —­ ' . Sealing Material (top 50y <br /> Depth z- '-'Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑"REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is <br /> available within 200 feet.) <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: <br /> SEPTIC TANK Water table depth <br /> � Type/Mfg - ` p r� �ti-Capacity No. Compartments <br /> PKG. TREATMENT PLT. F] Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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,I shall employ persons subiect to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. C <br />[ X Signed X Title: <br /> I _ Li <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area CJ' <br /> i <br /> Pit or Grout InspectionDate Final Inspection by Date— <br /> Additional Comments: <br /> ❑ Stk 466-6781 , .❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 I <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2409, Stk., CA 95201 <br /> r <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY <br /> INFO C DATE PERMIT*NO. <br /> + EH 13-24(REV.i i H sl <br /> EH 1429 39 <br />