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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE_ STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES TYEAR 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. i <br /> Job Address City_ X e�= Lot Size /PM <br /> Owner's Name hy?"+� Address —1cE Phone ! T <br /> Contractor Zjte <br /> �,ess�/ � 1J/4C�i�'lilicense No."i�c �Phone <br /> TYPE OF WELL./PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION�,oQ�P4,249>ZqYSTEM 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 <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public n Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth L I Eastern Surface Seal Installed by pp _ <br /> Repair Work Done ❑ Type of Pump" H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material 18elow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIWADDITION I I DESTRUCTION I 1 lNo septic system permitted it public sewer is <br /> available within 200 feet,l lJ <br /> Installation will serve: Residence_ Commercial_ Other G <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth 0 <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 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I 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 I oagiiin1'county-ordinances,,state laws, and <br /> rules and regulations of the San Joaquin Local Health District. ` C e <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance offth�ajwork for which this permit is issued, I shall no <br /> employ any person in such manner as to become subject to workman's compensation laws of California.''jisontractor'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 emOlby pers6h-S subject to-whfkman's compensa- <br /> tion laws of California." <br /> The applicant t c II or 11 requiTsidinspections. Complete drawing on reverse de. <br /> Signed 1TitW Date: : <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by Date Area 9,0 <br /> Pit or Grout Inspection by Date Final Inspection by.1 Dated g <br /> Additional Comments: L _ <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 4 CASH RECEIVED BY DATE PERMIT'NO. <br /> a EH 1 <br /> 3-24{REV.i/n 51 <br /> EH 14-26 / Sr <br />