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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) 466-67$1 <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 AddressI A/U CityAA TilleQ? Lot Size T� � _ PM <br /> 'Owner's Name Address _>� ZA 10 4) Phone <br /> Contractor's Name t. J License No. p,/5-0r -D— Phone .2-347 a <br /> TYPE OF WELL/PUMP: NEW WELL ❑ : WELL REPLACEMENT ❑ DESTRUCTION ❑ -t= <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 Weil Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other - . �d -❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth, • ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. L State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler'-Material (Below 501 L <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is it7 <br /> available within 200 feet.) <br /> Installation will serve: Residence-Y Commercial_ Other <br /> Number of living units:_L__ Number of bedrooms 3 <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 <br /> Distance to nearest: Well Foundation Property Line J <br /> LEACHING LINE ❑ No. & Length of linesc4�`� ^) sem oundation Total length/size <br /> FILTER BED r 1�( Distance to nearest]+WeTl' <br /> r � � Property Line <br /> SEEPAGE PITS Depth, Size - -- Number ••--- <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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."Contractors 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 r quired inspections. Complete drawing on reverse side. . <br /> Signed X z4 Title: OZ4dAA deje Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by CA4`_ Date ��'�� Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 .❑ Lodi 36.9-3621 ❑ 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 13-24(REV.10183) r ' 1� �I <br /> � <br /> EH 1426 "{ © � , "�'7 S�•.5 <br />