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APPLICATION FOR PERMIT <br /> Fa <br /> SAN JOAO.UIN LOCA' L'HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES-1rYEAR FROM DATE ISSUED:'- <br /> (Complete <br /> SSUED''(Complete in Triplicate)- <br /> Application <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 ti <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and.the R41es and Regulations of the San Joaquin <br /> Local Health-.District. . i! ,. . <br /> Job Address /_73a ( L <br /> Ci Lot Size t PM <br /> Owner's Name { Address Phone " <br /> Contract cc Address �! } ­7ee7 License No. off Phone, k?, dS \� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ `V <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 f L W <br /> 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 /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth filler Material (Below 50') -S. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ (REP!!;ADDITION ❑- DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will server Residence Commercial— Other <br /> Number of living units: Number of be rooms <br /> Character of soiFto a dep#h of3 feet:j Water table depth <br /> SEPTIC TANK s } Type/Mfg I Capacity No. Compartments <br /> PKG. TREATMENT PLT..❑ r } i ,N € r Method of Dispose] i <br /> Distance to nearest: Well Foundations_. �+ ' ` . <br /> v P.ropertyyLirie_.__ <br /> LEACHING LINE Ik :No...&_Length_of_lines_ �" Total length/size anoX <br /> FILTER BED ❑ 'Distance to nearest: Well ®r r-'7 f I _ <br /> Foundation /� "Pr•o'�rty L"fine'* �� <br /> 1 v 'f <br /> SEEPAGE PITS ❑ `Depth -11 F Size r Number <br /> SUMPS El Distance to nearest:, Well Foundation Property Line <br /> DISPOSAL PONDS Q I <br /> 1 hereby certify that I have prepared this application and that thq_work-will'be done in accordance With San Joaquin county o d nances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District—; . . ' 3 ". ' i r <br /> Home owner or licensed agent's-signature-certifies,the•followingi "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ an ; <br /> p y y person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or-soli-contracting signature <br /> certifies the following."I certify that in the performancelof�tf e',wo'rk for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." . <br /> The applicant t call for all uire inspections. Complete drawing on reve side. <br /> SignedX__r Title: Date:`L! <br /> OR pEPARTMENT USE ONLY <br /> �2 i <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by I Date Final Inspection by Date .2-fl-0 <br /> Additional Comments: 4(&714& ';5&PTic ;90�y& AAIb- u <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO AMOUNT DUE �I AMOUNT REMITTED .CASH RECEIVED BY DATE PERMIT`NO. <br /> + EH 13-24(REV.z/a 5) t.•! S " e- <br /> EH 13-28 Q II n <br />