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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 TYEAR FROM DATE ISSUED <br /> a I (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 welilpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address a.HW City Lot Size PM <br /> Owner's Name Address v 16 r�_-a e Phone <br /> Contract i Address 7 License No. �Ro Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r ` <br /> {" <br /> r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> r^A'+ FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS {t' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS # <br /> & 13 Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> T <br /> = <br /> [-]',Public ' 17-1 Other F1 Delta Depth of Grout Seal Type of Grout 1 � <br /> I I Irrigation ' ­-Approx. Depth I�I Eastern Surface-Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. _. _State Work.Done _ <br /> Well Destruction -`S—Well-Diameter------ Sealing-Material![top,50']•--�---� <br /> Depth e,Material (Below 'I <br /> TYPE OF SEPTIC WORK NI_ -INSTALLAJ�ON{1 REPAIR ADDITION I DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> t / available within 200 feet./ <br /> ` <br /> Installation will serve: Residence_ Commercials Other <br /> Number of living units: 1—Numbei of edrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑" Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑. ;, 1 1. Method of Disposal <br /> R <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINENo:&Length oflines Qy� Total length/size <br /> I FILTER BED ❑ Distance to nearest: Well ,�Ci Foundiion ..__. Property Line <br /> A <br /> SEEPAGE PITS" I l: Depth Size Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> } DISPOSAL PONDS ❑ , <br /> i <br /> I I hereby certify that I have prepared this application and that the work will he 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 /> t 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 muM; 4,9 <br /> fr all a uir inspections. Complete drawing on reversr <br /> Signed X Title: Datei` !//• f)v <br /> FOR DEPARTMENT USE ONLY <br /> s t„ Application Accepted by Date <br /> Pit or Grout Inspection by Date Final Inspection by Date�� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 838-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT NO. <br /> INFO CASH <br /> re O <br /> , <br /> ,�+ + EH 13-24 IREV.5 i x 51 /�I IP-3 <br /> r� <br /> ' EH 14-28 ' <br /> , <br />