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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT t <br /> 1641 E. HAZE T ON AVE., STOCKTON, CA 1 <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. mm. <br /> . , <br /> Job Address I�Y a ."IE ' City - Lot"Size PM <br /> i Owner's Name ° Addresses' Z .S Z Ci S" Phoney ' <br /> Contractor r Address '�� License No. Phone`-^ <br /> ` TYPE OF WELL/PUMP: NEW WELL 13WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> .. - <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE <br /> ^DISTANCE TO NEAR -S TIC TANK— "SEWER LINES- D. . PROP. LINE - <br /> FOUNDA AGRICULTURE OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROS CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial El Open Bottom�' ''6Manteca 4 ell Excavation Dia. of Well Casing <br /> ❑ Domestic/Private © Gravel `aPck ❑ Tracy Type of Casing Specifications + <br /> ❑ Public EJ'`7�Other; ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigatio __�Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter: Sealing Material (top 501 <br /> _ _ .._ - <br /> Depth'-" Filler Material {Below 50'} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION El DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> r . <br /> Installation will serve: Residence_ Commercial_ Other <br /> 4 Number of living units: Number of bedrooms x <br /> " Character of soil to a depth of 3 feet: 42 0 Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No, Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: -Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size 1 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: . Well Foundation Property Line <br /> DISPOSAL PONDS ❑- <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 Joaqulh 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." I; <br /> The applicant u call for all equi spections. Complete drawing on reverse side. <br /> / Qi <br /> Signed itie: ✓ /�--�1-� Date: 3 [� r <br /> a M <br /> FOR DEPARTMENT USE ONLY 4 <br /> Application Accepted by Date — Area <br /> Pit or Grout Inspection Date w.. Final Inspection by Date <br /> Additional Comments: 0� <br /> ❑ Stk 466-6781 ❑ Lodi 359-3621 ❑ Manteca 823-7104 ❑ Tracy 83540% <br /> Applicant-'Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> + EH 13-24 4REV. /a sl '� �/7`� �r�97 id I C_ <br /> EH 14-26 _ _ <br />