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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).466-6781.1 <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 /> lAr 3� A] ?y ,t/L(fid Ci Lot Size PM <br /> 1 Job Address �1 / �,/.. <br /> Owner's Name <br /> ,� } Address ^�0[a • "�`�" & Phone - <br /> L �S!O <br /> Contract Address Pg License NoZ Z Z Phone rn <br /> I TYPE OF WELL/PUMP: �� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: OPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> . S <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i ❑ Industrial ❑'Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing, <br /> Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 5 p <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation . Approx. Depth ❑ Eastern Surface Seal Installed by <br /> rState Work Done <br /> Repair Work Done EJ Type of Pump H.P. <br /> .f I <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> r _ Depth iller Material [Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ElEPAIR DDITION 8' DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> t <br /> !} Installation_will,serve: <br /> R'sideace Commercial Other ` <br /> Number of living units: Number Number of be ours L <br /> + urs �] k <br /> Character of so I_to_a_depth_of 3 feet: Water table depth <br /> Type/Mfg CCapacity_ No. Compartments <br /> D i <br /> SEPTIC TANK i <br /> PKG. TREATMENT PLT. ❑II 1`�; "� Method of Disposal <br /> i�Distance to nearest: Well Foundation - property Line <br /> LEACHING LINE, i❑ No. & Length of lines �y Total dengthlsize <br /> " l Foundation +`Property Line <br /> FILTER BED% } ❑ � Distance to nearest: Well_ ` <br /> SEEPAGE PITS i❑:I Depth Size Xumber_ <br /> l _ ♦ :r t <br /> SUMPS - �:♦IL Distance-to.nearest: --Well_ _ Foundation �Q Property Line <br /> DISPOSAL PONDS iy❑, I <br /> 1 hereby certify that I have•prepar'ed 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 certifi&s the following: 111 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 whichthis permifi§issuedl shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The-applica ust-call-f II-. quired-inspections.-Complet`a drawingfon reverse Ve. <br /> E `Title: �I Dater <br /> Signed _ <br /> — FOR DEPARTMENT USE ONLY <br /> Application Accepted by � Date Area � I <br /> I ate 7 Final Inspection by <br /> Pito ut Inspection by <br /> A r o a o�r1'fdltts: ? <br /> ❑ 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 /> II� i <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE ,PERMIT'NO. <br /> INFO <br /> gb._LSr <br /> +EH 13-24(REV.7/951 +i <br /> EH 14-26 4� <br /> 11 <br />