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APPLICATION`FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'r • <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA ,•. <br /> Telephone 12091 466-6781 <br /> T PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> f 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. `CQ f <br /> Job Address <br /> q7 Db� E) City `� Lot Size " ` 15QM <br /> Owner's Name Address Phone <br /> I Contjact0r%W LT t+au- Address icense.No:y n Phone <br /> T TYPE OF WELLIPUMP:_ _NEW.WELL D,—WECL,�REPLACEMENT-El, -.___DESTRUCTI. N 0 <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 /> F" INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F Public n Other Cl Delta Depth of Grout Seal Type of Grout <br /> I 1 Irrigation —.-Approx. Depth i I Eastern Surface Seal Installed by <br /> Repair Work Done - ❑ Type of Pump - <br /> - -� �H-P- - -' State Work Done <br /> Well Destruction C] Well Diameter ? _ Sealing Material [top 50') <br /> Depth T } - Filler Material [Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION d l DESTRUCTION l eptic system permitted if public sewer is <br /> available within 200 feet.] <br /> q (� <br /> installation will serve: Residence uCommercial— Other" v} <br /> Number of living units: Number,of bedrooms <br /> Character of soil to a depth of 3 feet: Y Water table depth <br /> I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. © t s- _ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> I <br /> FILTER BED ❑- Distance to neares'ti' Well Foundation Property Line <br /> SEEPAGE PITS I I Depth + Size _ Number <br /> 1 SUMPS L-! Distance to nea-resC's Well Foundation Property Line <br /> DISPOSAL <br /> PONDS- ❑ F <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. 1 <br /> Home owner or licensed agent's signature certifies the following:_I certify that'in`the pe_tformance of the work for which this permit is issued, I shall not <br /> P loy any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> c-­_ <br /> er e 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 o lit rni ♦ i <br /> T plica "m call fo all uir inrt eto drawing on reverse side. <br /> Signed X r Title: Date:, r <br /> .,F.O MENT-USE-ONLY,..,,,. .P._.. <br /> Application Accepted by + Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date '" <br /> a <br /> Additional Comments: <br /> F ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 L] Tracy 835-6385 <br /> I. Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> t _ <br /> INFO AMOUNT DUE AMOUNT REMITTED CA 4 RECEIVED BY DATE PERMIT'NO. <br /> ♦ EH13.24{DEV.1/8 51 cyo <br /> EH 14-28 <br />