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_ APPLICATION FOR PERMIT <br /> i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 ' <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> {Complete in'Triplicatel .�.r.. <br /> Application is heFeby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> l made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. F ' <br /> / <br /> i G City Lot Size PM <br /> Job Address- r <br /> Owner's Name <br /> ass Phone � r <br /> i <br /> l Contractor rass <br /> _1/2_(e_�— _,�,04W <br /> License NoPhone <br /> TYPE OF WELL/PUM NEW WELL ❑ WELL WELL © DESTRUCTION ❑ <br /> PUMP INSTALLATION 71 SYSTEM REPAIR ❑ OTHER 11 <br /> DISTANCE.TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial <br /> El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. f Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications — <br /> I 1 Public <br /> f 1 Other Cl Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation ..Approx. Depth i I Eastern Surface Seal Installed by <br /> Repair Work Done ElType of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter a Sealing Material-Itop 50'1 - <br /> Depth - Filler Material (Bel 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION (I REPAIR/ADDITION X DESTRUCTION l 1 (No septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Re 'dente Commercial— Other <br /> Number of living units: T Number of bedrooms <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. <br /> El of Disposal <br /> Distance to nearest: Well Foundation Property.Line <br /> ! Total.length/.size <br /> I LEACHING LINE No. & Length of lines D <br /> FILTER BED El .Distance to nearest: Well Foundation _' 'P�party Line <br /> SEEPAGE PITS l 1 Depth Size <br /> SUMPS ❑ Distance to nearest: Well Foundation -" Property Line <br /> t DISPOSAL PONDS ❑ <br /> F I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin co <br /> unty 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 /> t employ any person in such manner as to become subject to workman 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 subject to workman's compensa- <br /> tion laws of California." <br /> The applicant I all uired n cti ns. Compl a wing on reverse side. I �� <br /> Signed X Title: <br /> k Date: <br /> FOR DEPARTMENT USE ONLY a <br /> Date Area�•� <br /> Application Accepted by <br /> Pit or-Grout Inspection by Dat Final Inspection by "r Date 4 <br /> Additional Comments: <br /> All <br /> ❑ Stk 466-6781 11 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 5 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., .O <br /> 0 Bax 2009, Stk., CA 95201 <br /> AMOUNT DUE AMOUNT REMITTED CK' RECEIVED BY DATE PERMIT'NO. <br /> FEE CASH <br /> INFO <br /> r.EH 13-24 IREV.v n 51 <br /> P EH t4-26 <br />