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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <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 /> Job Address O 02-L'!? A L fj-....__ City tlfc LO ~'I Lot Size / I-%<+" 6-%C-5 PM <br /> Owner's Name f-- {� 1 1( i l�- _1� Address ,:4_!S c )IJ= 1 YZ Phone �G x <br /> Contractor ( 'V DL LliS Address LL)- il_nil 41-2 License Noc9? F-A Phone-� � ✓ ' <br /> TYPE OF WELL/PUMP: NEW WELL W WELL Ki PLACEMENT ❑ 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 PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ <br /> ❑ Industrial 'Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i5 <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing .- !e- Specifications <br /> f`l Public FI Other f 1 Delta Depth of Grout Seal n Ty of <br /> F"J1 <br /> I I Irrigation s//�_Approx. Depth I 1 Eastern Surface Seal Installed by � jn^� <br /> Repair Work Done ❑ Type of Pump '` -� H.P.�� _ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted if public sewer is N <br /> available within 200 feet.) � <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: 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. ❑ Method of Disposal 1 <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 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 must call for all required inspecti9ps. Complete drawing on reverse side. <br /> , n <br /> Signed Title: �f- ! Date: - <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by i Date ',S4 - `TD Area {} <br /> Pit or Gr Inspection by Date b y/-�� Final Inspection by bate <br /> Additional Comments: <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 /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMIT N0. <br /> + EH 14-24 IREV.r H51 DD <br /> EH i4-2a <br />