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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT NAY <br /> 2 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA ;984 <br /> Telephone (209) 466-6781 SAN `oAotfll <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4t <br /> 1.ST1 . <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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address Uksl Dir A,r' / PrC� Rd City Lot Size. 4-2g QC PM <br /> Owner's Name QIA Address Phone <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL--PIT`StSUMPS�_ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f� <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ^�~ <br /> ED 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 Pum H.P. <br /> Pump State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) C <br /> Installation will serve: Residence e Commercial— Other <br /> Number of living units: ., Number of bedrooms- 7- <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Z;;;����Capecity/ge�26 �No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal � <br /> Distance to nearest: Well Foundation Property Line t; <br /> LEACHING LINE ❑ No. & Length of lines JC -76 Total length/size <br /> FILTER BED ❑ Distance to nearest: Well $D z Foundation 30'` _ Property Line 7Q! A <br /> SEEPAGE PITS ❑ Depth Size 10 Number \ <br /> SUMPS ❑ Distance to nearest: Well FoundationProperty Line <br /> DISPOSAL PONDS F1 1q_ <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. <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 /> 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 rrAust call for all required inspections. Complete drawing on reverse side. <br /> Signed X 9.0 Title: cx� <br /> Date: XZ <br /> / FOR DE ARTMENT USE ONLY <br /> Application Accepted by v_ Date ��? r Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additions! Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 /> FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED 8Y DATE PERMIT"N0. <br /> INFO CASH <br /> EH 13-24(REV.10!831 S a O .� � Q <br /> EH 1426 c>Li <br />